Multisystem inflammatory syndrome in children in South Africa

There are reports of a multisystem inflammatory syndrome in children associated with COVID-19 known as MIS-C or paediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (PIMS-TS).1, 2, 3 The definition of MIS-C issued by WHO includes clinical and laboratory features, with evidence of COVID-19, or likely contact with a person who has or has had COVID-19.⁴

South Africa has the most reported COVID-19 cases in Africa, with the Western Cape Province acting as the initial epicentre with a total of 93 414 people with confirmed COVID-19 by July 31, 2020, of whom 2910 were younger than 15 years old.⁵ We have summarised the first 23 cases of MIS-C treated at The Red Cross War Memorial Children's Hospital, Cape Town, South Africa, and the Tygerberg Children's Hospital, Cape Town, South Africa, from June 4 to July 24, 2020 (appendix).

With the surge of the pandemic further north throughout the continent, we expect continued reports of MIS-C in South Africa and sub-Saharan Africa. We encourage regional child health professionals to practice vigilance and create structured referral pathways to specialist centres.

Proving previous COVID-19 disease (or SARS-CoV-2 infection), or likely contact with someone who has had COVID-19, is a limitation in these data because of poor access to SARS-CoV-2 antibody testing and restricted community testing in the region. We suggest that this should not prevent the diagnosis of MIS-C after the careful exclusion of other conditions in regions with evidence of community spread. Most of this cohort had no confirmed or suspected infection or no contact with COVID-19 and no access to antibody tests, but all met clinical diagnostic criteria and had likely community contact with the disease. Black children were relatively over-represented in this cohort, but we do not have the relevant hospital denominator data to confirm this as a significant finding. A high level of suspicion is required during diagnosis because the presenting features of MIS-C were non-specific (persistent fever, rash, and abdominal pain). Two children in this cohort had laparotomy for suspected appendicitis. 12 (52%) of the 23 children required admission to an intensive care unit, most commonly because of myocardial dysfunction. Anecdotally, the degree of cardiac dysfunction was often underappreciated, which delayed diagnosis and closer attention to age-inappropriate persistent tachycardia and relative hypotension is warranted. All 23 children received intravenous immunoglobulin, with 15 (65%) children requiring additional drugs (such as methylprednisolone, a second intravenous immunoglobulin, or tocilizumab), all of which might not be universally available or affordable. Global data on the responses to therapy are urgently needed.

There are ongoing admissions of MIS-C to the hospitals. Despite being critically ill, all children have survived to date with no discernable irreversible disease sequelae and we will be monitoring these children into the future.