A wide spectrum of symptoms and disease severity may characterize patients presenting with pediatric inflammatory multisystem syndrome (PIMS-TS) associated with SARS-CoV-2, including fever and inflammation, myocardial injury, shock, and development of coronary artery aneurysms, according to a study published in JAMA.

The study included 58 pediatric patients from 8 hospitals in England who were admitted between March 23 and May 16, 2020, with persistent fever and laboratory evidence of inflammation, who met the Royal College of Physicians definition of PIMS-TS. Data including clinical and laboratory characteristics were extracted from both electronic and paper records. This data was then compared with clinical characteristics of patients with Kawasaki disease (KD) (n=1132), KD shock syndrome (n=45), and toxic shock syndrome (n=37) who had been admitted to hospitals in Europe and the United States from 2002 to 2019.

The median age of patients was 9 years; 33 were girls (57%) and 40 (69%) were black or of Asian descent. Most patients were previously healthy, although a small number of children had comorbidities including asthma (n=3), neurodisability (n=1), epilepsy (n=1), sickle cell trait (n=1), and alopecia (n=1).

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All patients presented with persistent fever for 3 to 19 days and nonspecific symptoms such as abdominal pain (53%), rash (52%), and conjunctivitis (45%).  Twenty-nine patients required admission to the intensive care unit and 13 developed acute kidney injury.

Results from SARS-CoV-2 RT-PCR tests were positive in 15 of 58 patients (26%), indicating active disease, and SARS-CoV-2 immunoglobulin (Ig)G antigen test results were positive in 40 of 46 (87%), indicating previous infection. Laboratory evaluation was consistent with marked inflammation: for example, elevated C-reactive protein (CRP, 229 mg/L) and ferritin (610 µg/L) were found.

Of the 58 children, 29 developed shock and required inotropic support and fluid resuscitation (including 23 of 29 who required ventilation); 13 met the American Heart Association definition of KD and 23 had fever and inflammation without features of toxic shock or KD.

Comparison of PIMS-TS with KD and with KD shock syndrome showed differences in clinical and laboratory features, including older age (9 vs 2.7 years and 3.8 years, respectively) and greater elevation of inflammatory markers such as C-reactive protein (median, 229 mg/L vs 67 mg/L and 193 mg/L, respectively).

“When PIMS-TS cases with coronary artery aneurysms were compared with pre–COVID-19 KD cases that developed coronary artery aneurysms, children with PIMS-TS tended to be older, have more intense inflammation, and have higher levels of markers of cardiac injury, suggesting that these are 2 separate entities and that treatment for PIMS-TS may need to be different than that for KD,” concluded the authors. “Various biomarkers, including CRP, ferritin, troponin, and [N-terminal (NT)-pro hormone BNP] levels may be helpful in predicting progression of disease.”


Whittaker E, Bamford A, Kenny J, et al. Clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 [published online June 8, 2020]. JAMA. doi:10.1001/jama.2020.10369