Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case Series
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : BR01 - BR04 Full Version

Biochemical Investigation of Multisystem Inflammatory Syndrome in Children (MIS-C) with SARS-CoV-2 Infection: A Series of seven Cases


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52534.16436
Kamalakar Bhagwat Mane, Swati Digambar Sawant

1. Associate Professor, Department of Biochemistry, Dr. Vaishampayan Memorial Govt. Medical College, Solapur, Maharashtra, India. 2. Assistant Professor, Department of Biochemistry, Dr. Vaishampayan Memorial Govt. Medical College, Solapur, Maharashtra, India.

Correspondence Address :
Swati Digambar Sawant,
Assistant Professor, Department of Biochemistry, Dr. Vaishampayan Memorial Govt. Medical College, Solapur, Maharashtra, India.
E-mail: drswatitalekar@gmail.com

Abstract

In children, Coronavirus Disease 2019 (COVID-19) is typically mild. However, in rare cases, children are severely affected, and clinical manifestations are differed from adults. The consequence of COVID-19; Multisystem Inflammatory Syndrome in Children (MIS-C) is a rare complication that seems like toxic shock syndrome or Kawasaki Disease (KD). The MIS-C is characterised by an inflammatory response in the body that occurs four weeks after infection with the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus. Fever, rashes, diarrhoea, red eyes, and vomiting are common early symptoms that can worsen over time. The inflammation can affect the blood vessels, heart, and other organs, leaving children critically ill and in need of immediate medical attention. Many of the children with MIS-C show positive SARS-CoV-2 serology but negative Polymerase Chain Reaction (PCR), supporting the concept that MIS-C is linked to immunological dysregulation that develops after the acute infection has passed. However, some children do have positive PCR testing. A case series of seven critically ill children with MIS-C in sequential order of admission in the Paediatric Intensive Care Unit (PICU) of tertiary care hospital is illustrated. Key findings of this syndrome include fever, epilepsy, diarrhoea, shock and variable presence of rash. In the present case series, the clinical features, laboratory findings and therapies for a cohort of seven children with MIS-C are presented. Laboratory investigations carried out at early stage of disease can be of vital importance to diagnosis of MIS-C.

Keywords

Acute infection, Coronavirus disease, Inflammatory markers, Kawasaki disease

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was initially detected in December 2019 in Wuhan, China. The World Health Organization (WHO) formally identified this infection, Coronavirus Disease-2019 (COVID-19), and the virus as SARS-CoV-2 on 11th February 2020. On 11th March 2020, the World Health Organization announced a pandemic (1).

The SARS-CoV-2 typically causes pneumonia in adults and Acute Respiratory Distress Syndrome (ARDS). It is now being identified as a multisystem disorder. Most children, on the other hand, are asymptomatic or have a mild-to-moderate disease. Severe or life-threatening illness is unlikely in children (2). Children are increasingly being identified with a new condition known as Multisystem Inflammatory Syndrome in Children (MIS-C). Children with MIS-C are sicker, often require intensive care, and could have multisystem involvement and multiorgan dysfunction (3).

Case Report

A case series of seven critically ill children with MIS-C in sequential order of admission in the Paediatric Intensive Care Unit (PICU) of tertiary care hospital is illustrated. Findings observed in this case series were fever, epilepsy, diarrhoea, shock, variable presence of rash and the laboratory findings of Biochemistry, Pathology and Microbiology. Case history including significant clinical features, significant laboratory findings, and therapy given according to standard guidelines for a cohort of seven children with MIS-C is outlined in this case series.

Case 1

A 9-year-old male child presented to Department of Paediatric with fever, convulsion, loose motions, breathlessness and headache since 1 day. There was no significant past medical history or family history. The COVID-19 antibody test was positive. The Rapid Antigen Test (RAT) for COVID-19 was negative.

Patient in delirium state with Glasgow Coma Scale (GCS) 11/15 was admitted to PICU with provisional diagnosis of fever activated epilepsy. On admission, significant laboratory findings were raised inflammatory markers C-reactive Protein (CRP) (157 mg/L), Lactate Dehydrogenase (LDH) (668 U/L) and D-dimer (1140 ng/mL) (Table/Fig 1). Computed Tomography (CT) brain, fundus examination and 2D Echocardiogram (ECHO) revealed no abnormality. A diagnosis of fever activated epilepsy with MIS-C was made. Patient developed hypotension (blood pressure was-96/50 mmHg). Inotropic support, Intravenous immunoglobulin, anticonvulsants, methylprednisolone and enoxaparin were given. The patient was improved and discharged on 11th day of admission.

Case 2

A 6-year-old female presented to Department of Paediatric with chief complaint of loss of consciousness for 2 hours, unknown bite marks with swelling over lower left foot and discolouration of body for 1 day.

On physical examination, ecchymotic patches over both lower limb and upper limbs were present. With GCS of 3/15, patient was admitted and intubated. The COVID-19 IgG was positive. On admission, significant laboratory findings were, raised inflammatory markers viz. CRP (118 mg/L), LDH (593 U/L), D-dimer (910 ng/mL) and leucocytosis (17.7×103/uL) (Table/Fig 1). The CT brain, fundus examination and 2D ECHO revealed no abnormality. Patient was provisionally diagnosed as a case of unknown bite but final diagnosis was Multisystem Inflammatory Syndrome in Children (MIS-C). After admission, the patient developed fever. Intravenous immunoglobulin, anticonvulsants, methylprednisolone and enoxaparin were given. Patient condition improved and was discharged on 18th day of admission.

Case 3

An 8-year-old female child presented to Department of Paediatric with vomiting, loose stool for 1 day and unconsciousness for 3 hours. Patient was admitted to PICU with GCS of 3/15 with respiratory failure and shock. On admission, significant laboratory findings were noticed like raised CRP (44.1 mg/L), LDH (1271 U/L), D-dimer (700 ng/mL) and leucocytosis (13.59×103/uL) (Table/Fig 1). The COVID-19 antibody test was positive. Cerebrospinal Fluid (CSF) analysis was done. The CT brain, fundus examination and 2D ECHO revealed no abnormality. Patient was provisionally diagnosed as viral encephalitis and finally diagnosed as acute viral encephalitis with MIS-C. Patient was intubated on admission. Patient also developed hypotension for which inotropic support was initiated. Intravenous immunoglobulin, anticonvulsants and methylprednisolone were given. The patient condition was improved and was discharged on 13th day of admission.

Case 4

A 2-month-old male child presented to Department of Paediatric with fever, grunting sounds, abdominal distension, hyperpigmented rash all over the body and respiratory distress for 1 day. The RAT for COVID-19 was negative. The COVID-19 antibody IgG was positive. On admission, significant laboratory findings were raised CRP (25.9 mg/L), LDH (1200 U/L), D-dimer (610 ng/mL), Ferritin (2000 ng/mL), CK-MB (15.9 ng/mL) and leucocytosis (11.72×103/uL) (Table/Fig 1). The CSF analysis was suggestive of meningitis revealing nucleated cells, polymorphs, lymphocytes. CSF sugar and CSF protein were 40 mg/dL and 70 gm% respectively. The CT brain, fundus examination and abdominopelvic Ultrasound (USG) revealed no abnormality. He was provisionally diagnosed as a case of meningitis and finally diagnosed as MIS-C with meningitis. The baby was treated with intravenous immunoglobulin, anticonvulsants and methylprednisolone. Patient improved and was discharged on 5th day of discharge.

Case 5

A 2-year-old female child presented to Paediatric Emergency Unit with sudden onset moderate to high grade fever for 1 day was admitted to PICU. The RAT for COVID-19 was negative. Her COVID-19 antibody IgG was found positive. On admission, significant laboratory findings were raised CRP (30.6 mg/L), LDH (752U/L), D-Dimer (559.3 ng/mL) and leucocytosis (7.2×103/uL) (Table/Fig 1). Her younger sibling was COVID-19 IgG positive. Patient’s provisional and final diagnosis was MIS-C. The patient was treated symptomatically and discharged on improvement. The patient was improved and discharged on 7th day of admission.

Case 6

A 5-year-old female child presented to Department of Paediatric with fever, convulsions and unconsciousness for 3 hours. Patient was immediately admitted to PICU. The COVID-19 IgG antibody test was positive. The CT and Magnetic Resonance Imaging (MRI) revealed no abnormality. On admission, significant laboratory findings were raised Ferritin (981.1 ng/mL), CRP (124.56 mg/L), LDH (1962 U/L) and leucocytosis (8.12×103/uL) (Table/Fig 1). Patient was intubated. A diagnosis of MIS-C was made. She was treated with intravenous immunoglobulin, anticonvulsants and methylprednisolone. The patient condition was improved and was discharged on 7th day.

Case 7

A 3.5-year-old female child presented to Department of Paediatric with fever, vomiting for 1 day, convulsions and loss of consciousness for 4 hours. The COVID-19 IgG antibody test was positive. Patient was in hypotensive shock on admission admitted to PICU for inotropic support and mechanical ventilation owing to respiratory distress from cardiac dysfunction. On admission, significant laboratory findings were raised CRP (121 mg/L), LDH (1028 U/L), CK-MB (37.8 ng/mL), SGOT (110 U/L) (Table/Fig 1). The CT brain revealed acute infract in right Internal Carotid Artery (ICA) territory while fundus examination and 2D-ECHO revealed no abnormality. Provisional diagnosis was status epilepticus and final diagnosis was cardiorespiratory arrest in right ICA territory with status epilepticus and MIS-C. She was treated with methylprednisolone but she succumbed to death on 4th day of admission.

All the details of cases- Biochemistry, Microbiology, CSF examination, haematology and urine examination are provided in (Table/Fig 2).

Discussion

The incidence of SARS-CoV-2 infection was reported 322 per 100,000 in persons under the age of 21, while of MIS-C was reported 2 per 100,000 (4). A large number of cases were found in Hispanic and Black children, with a modest number of occurrences in Asian children. In three case studies, Black children accounted for 25 to 45% of cases, Hispanic children for 30 to 40%, White children for 15 to 25%, and Asian children for 3 to 28% (4),(5),(6).

Many affected children’s Polymerase Chain Reaction (PCR) for SARS-CoV-2 tests were negative but had positive serological tests. This data supports the concept that MIS-C is linked to immunological dysregulation following acute infection (5),(7).

In MIS-C and severe acute COVID-19, clinical characteristics are overlapped. The MIS-C can be distinguished from severe acute COVID-19 infection by different patterns of organ system involvement and clinical presentation. Prominent feature in severe acute COVID-19 is severe pulmonary involvement (i.e., pneumonia, acute respiratory distress syndrome). Respiratory symptoms are common in MIS-C patients, although they are a result of shock or impaired cardiac function. Gastrointestinal symptoms (mostly abdominal pain) are also more common in MIS-C than in severe acute COVID-19 infection (8).

The MIS-C shows greater levels of inflammatory markers (CRP, D-dimer, and ferritin) than severe acute COVID-19, and lymphopenia and thrombocytopenia are more prevalent with MIS-C (8).

The timing of appearance of symptoms in MIS-C is variable. The time between acute infection and the appearance of MIS-C symptoms in children with a known history of COVID-19 is usually two to six weeks in children with a known history of COVID-19. Rare cases of MIS-C have been recorded that occurred more than 6 weeks after the acute SARS-CoV-2 infection (9).

In the prognosis, diagnosis, and management of children with MIS-C, laboratory biomarkers play an integral role. Apart from these additional clinical signs, fever is an ubiquitous indicator that occurs in a variable percentage of patients. As a result, biomarkers are a vital adjunct in prompt diagnosis and therapy, which can save life. There have been several diagnostic criteria proposed (10). Authors have followed unique diagnostic criteria of MIS-C put up by the Centre for Disease Control and Prevention (CDC) case definition for MIS-C (11).

To rule out the common endemic causes of fever, authors had done a rapid malarial antigen test, peripheral smear for malaria, dengue NS1/NS2, and Widal test. All seven cases were tested negative for malaria, dengue and typhoid.

All the cases did not have underlying comorbidities. In all seven cases, laboratory findings were significant elevation of inflammatory markers, such as D-dimer, C-Reactive Protein (CRP), Lactate Dehydrogenase (LDH), Erythrocyte Sedimentation Rate (ESR), Procalcitonin (PCT). Raised ferritin was found in case 4. Other findings were hyponatraemia in cases 3, 4 and 7, raised urea in cases 1 and 4 suggestive of kidney injury, hypoalbuminemia in cases 1, 4, 6 and 7 and elevated Creatine Kinase-MB or CK-MB in cases 1, 4 and 7 suggesting myocardial impairment and heart failure.

Case 4 showed an increased serum ferritin level. Studies on ferritin levels in COVID-19 patients have revealed equivocal findings. It is unclear whether that was a bystander effect or an actual illness manifestation (12). One study and a meta-analysis showed ferritin levels could predict severe disease and mortality (13),(14). One retrospective study showed that ferritin played only a minimal role in deciding Intensive Care Unit (ICU) admission and the need for ventilation, as well as failure to predict mortality (15).

In all cases, there was elevated CRP showing higher than 25 mg/dL. While in cases 1, 4, 6, and 7 CRP levels were >100 mg/dL. Similar to the present study results, few studies showed, the majority of patients had elevated CRP and values greater than 100 mg/dL were common; CRP is a plausible, beneficial initial laboratory investigation for screening MIS-C patients as well as monitoring them after therapy (16),(17). When compared to non severe disease, children with severe respiratory disease and MIS-C had significantly higher serum CRP, PCT, platelet count, and sodium levels. (18),(19).

Authors found neutrophilic leucocytosis in all the cases. Neutrophils play an important role in the innate immune response. The formation of Neutrophil Extracellular Traps (NETs) is one of their functional mechanisms (20).

CSF findings in all cases were consistent with aseptic meningitis, as has been described in KD. Cases 3, 4, and 7 all had hyponatraemia, which has been reported in Kawasaki disease and may be pertaining to more severe inflammation and Kawasaki shock syndrome (21).

Biochemical markers of MIS-C include serum D-dimer, PCT, creatine kinase, and IL-6 (22). Some studies observed commonly reported abnormal laboratory parameters in children were leucocytosis, increased creatine kinase, elevated D-dimer, CRP, AST and ALT (22),(23).

Authors found abnormal microscopic and biochemical parameters in urine routine examination in five cases, which is similar to what was found in one study where urine biochemical parameters were studied to predict disease severity. Positive urine protein and urine glucose results were more common in severe and critical patients. The severity was not related to urine occult blood and specific gravity (24).

Intravenous Immunoglobulin (IVIG) and methylprednisolone were administered to the children in this case series, both of which have been shown to be effective in the treatment of Kawasaki disease. This was highly effective in most patients in reducing systemic inflammation, as indicated by fever resolution and improved cardiac function over days.

Six children were discharged from the hospital after their inflammatory laboratory markers recovered; they are normotensive, afebrile, and properly hydrated, and they do not require oxygen therapy. Despite treatment, case 7 succumbed to death as a result of severe MIS-C. The COVID-19 complications, such as MIS-C, can present in a wide variety of ways and should be considered in any severe acute febrile illness.

Laboratory studies of the disease’s biochemical, pathophysiological, and immunological processes are essential to provide understanding and prognostic indications into potential therapeutic targets, as well as to support vaccine development strategies.

Conclusion

Early laboratory investigations of inflammatory markers correlating with the diagnostic clinical features is an ultimate key to diagnose MIS-C. Laboratory investigations are helpful for early detection and timely management of MIS-C cases.

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DOI and Others

DOI: 10.7860/JCDR/2022/52534.16436

Date of Submission: Sep 22, 2021
Date of Peer Review: Dec 04, 2021
Date of Acceptance: Mar 15, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Dec 04, 2021
• Manual Googling: Mar 09, 2022
• iThenticate Software: Apr 13, 2022 (15%)

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