Study Compares Use of Corticosteroid Monotherapy, IVIG Treating Multisystem Inflammatory Syndrome in Children

Corticosteroid monotherapy was successful in treating a subset of patients with mild multisystem inflammatory syndrome in children (MIS-C), according to a study published in JAMA.

MIS-C is a rare complication of SARS-CoV-2 infection, which is characterized by symptoms such as fever, multiorgan involvement, and documented SARS-CoV-2 exposure. The study noted that approximately 80% of MIS-C cases present with cardiovascular symptoms and 74% of these patients develop mucocutaneous features that are similar to Kawasaki disease, with potential development of coronary artery abnormalities.

The study sought to compare short-term outcomes following initial therapy with corticosteroids, intravenous immune globulin (IVIG), or both, among patients with MIS-C as per the CDC case definition, who were treated in a tertiary-care pediatric hospital system between March 2020 and February 2021.

The study’s primary outcome was failure of initial therapy, which was defined as therapy escalation because of fever, or worsening or lack of improvement in laboratory, cardiac, or noncardiac clinical factors after 24 hours for patients admitted to the intensive care unit (ICU) or 48 hours for non-ICU patients from time of therapy initiation, per clinician assessment. Secondary outcomes of the study included the presence of complications, cardiovascular outcomes, fever duration, length of both hospital and ICU stays, corticosteroid use duration, and need for readmission.

The univariate analysis included 215 of 228 eligible patients, of whom 135 (62.8%) were boys and the median age was 8 years.

The researchers enrolled 69 patients who had milder disease at presentation in the corticosteroids cohort, 31 in the IVIG cohort, and 115 patients in the IVIG plus corticosteroids cohort. The investigators noted that after propensity score weighting of 179 patients (68 in the corticosteroids group and 111 in the IVIG plus corticosteroids group), the rates of initial treatment failure were similar between the cohorts.

The results showed that in patients whose initial treatment failed, the treatment failure in the IVIG plus corticosteroids cohort was more likely based on laboratory parameters (odds ratio [OR], 1.96; 95% CI, 1.07-3.60) and less likely based on cardiovascular markers (OR, 0.39; 95% CI, 0.2-0.76), per clinician assessment.

Patients in the IVIG plus corticosteroids cohort had a longer median inpatient stay of 6 versus 5 days (P = .001) and a longer median corticosteroid course duration of 10 versus 5 days (P = .04) compared with the corticosteroids cohort. Further, 49 of 69 patients in the corticosteroids cohort recovered following corticosteroid monotherapy for 10 days or less. All patients across the 3 treatment cohorts survived.

Of the study groups, 1 patient in the corticosteroids group, none in the IVIG group, and 3 patients in the IVIG plus corticosteroids were readmitted to the hospital within 6 months of diagnosis because of MIS-C symptoms. One patient in the IVIG plus corticosteroids group was readmitted due to SARS-CoV-2–induced encephalopathy.

The investigators observed that initial therapy with corticosteroids alone had similar rates of treatment failure, shorter median corticosteroid course duration, and shorter median total length of stay versus IVIG plus corticosteroids after adjusting for baseline presentation and severity. They also noted longer inpatient stay and corticosteroid course duration in the IVIG plus corticosteroids group, which may have been related to sequelae of severe disease, such as the need for inpatient rehabilitation and protracted inflammatory state.

The researchers concluded that this subset of patients with mild MIS-C were successfully treated with 10 days or less of corticosteroid monotherapy, which leaves for consideration the need for universal IVIG use.

“Failure of initial therapy was more likely due to cardiac-related reasons and less likely due to worsening laboratory parameters in the corticosteroid monotherapy group. This finding should be interpreted with caution, as reasons for therapy failure were based on clinician assessment; furthermore, the remaining objective cardiovascular outcomes did not differ between groups after adjusted analysis. Notably, the nonuse of IVIG did not translate into worse coronary outcomes,” the study authors wrote.

Reference

Villacis-Nunez DS, Jones K, Jabbar A, et al. Short-term Outcomes of Corticosteroid Monotherapy in Multisystem Inflammatory Syndrome in Children. JAMA Pediatr. Published online March 28, 2022. doi:10.1001/jamapediatrics.2022.0292. Accessed April 18, 2022.