Skin Symptoms in Most Children with Multi-System Inflammatory Syndrome Related to COVID-19

Much remains unknown about how SARS-CoV-2, the virus that causes COVID-19, affects children. While children tend to develop milder infections, some have developed Multisystem Inflammatory Syndrome in Children (MIS-C). MIS-C is an uncommon Kawasaki-like manifestation of COVID-19 that can rarely be fatal. Now, thanks to a recent study published in JAMA Dermatology, physicians may find clues in skin and mucous membranes that help them recognize the condition.

To pediatric rheumatologist Sirada Panupattanapong, MD, these findings aren’t surprising.

“Mucocutaneous symptoms have been very common in our patients with MIS-C. We’ve seen a lot of rash, erythema, edema and lip cracking, which are also seen in Kawasaki disease (KD),” Dr. Panupattanapong says.

Rash and conjunctivitis among symptoms of MIS-C

Pediatricians are well aware of the symptoms of KD, including high fever, flushed skin and eyes, rash, swollen hands and feet, strawberry tongue and bloodwork indicating an extremely high inflammatory response. “This case series suggests that mucocutaneous symptoms may help pediatricians catch the hyperinflammatory state earlier,” says Frank Esper, MD, an infectious disease specialist at Cleveland Clinic Children’s, who did not participate in the study.

The retrospective study reviews the cases of 35 hospitalized patients who had been diagnosed with, or met the criteria for MIS-C. Eighty-three percent of these patients had mucocutaneous symptoms. The symptoms were varied and included rash (80%), conjunctivitis (60%), changes in oral mucosa (57%), erythema (51%), edema (40%), lip hyperemia (49%) or cracking (37%) and strawberry tongue (23%). These symptoms occurred a mean of 2.7 days after fever onset, and the presence or absence of these symptoms were not associated with disease severity. The study authors also note several findings that may help differentiate MIS-C from KD, including periorbital edema and erythema, prominent malar erythema, and reticulated erythematous eruptions.

“The finding of malar erythema is striking, as it not seen in KD,” Dr. Panupattanapong explains. “We just had a young patient who presented with a rash on the body and legs, and erythema of cheek. At first glance, it looks like a viral infection. Similar to the patients in this series, our patient had negative results from PCR and antibody testing. Often, we can’t rely on PCR and antibody testing in MIS-C. Only a small percentage of patients will still have an acute infection, and the antibody tests just aren’t reliably sensitive.”

Other conditions can cause similar mucocutaneous symptoms, including other viral infections and allergic reactions. Given the high rates of community transition, however, physicians should be aware that COVID-19 is another possible cause, says Dr. Esper.

Understanding of COVID-19 in children still evolving

As this is a new evolving spectrum of our understanding of COVID-19 infections in the pediatric population, there is much to learn. It is important to reiterate that MIS-C remains rare and has only occurred in a small number of children and adolescents. Early recognition is crucial as these patients may be critically ill and require care in a pediatric intensive care unit as well as evaluation from multiple subspecialties including infectious disease, cardiology, hematology/oncology and rheumatology.

“About 20%-30% of patients will present with mild symptoms of MIS-C. They should be monitored, but their symptoms may resolve without intervention,” Dr. Panupattanapong adds.