, et al
Multisystem inflammatory syndrome in children—initial therapy and outcomes
N Engl J Med
; doi:

Investigators from multiple institutions conducted a retrospective study to evaluate the effectiveness of initial immunomodulatory treatments of children with multisystem inflammatory syndrome (MIS-C). For the study, they abstracted data from the Overcoming COVID-19 surveillance registry, which includes data on children diagnosed with MIS-C at participating US hospitals. At each participating site, demographic data and information on underlying conditions, signs and symptoms at presentation, clinical course, laboratory and medications, and outcomes were entered into a central database on patients meeting CDC criteria for MIS-C (serious illness leading to hospitalization in patients <21 years old, fever, laboratory evidence of inflammation, multisystem organ involvement, and evidence of SARS-CoV-2 infection).

For the study, the investigators focused their analyses on patients whose initial immunomodulatory treatment was either intravenous immunoglobulin (IVIG) alone or IVIG plus glucocorticoids (initial day of treatment designated as Day 0). The primary study outcome was evidence of left ventricular dysfunction, defined as left ventricular ejection fraction <55%, echocardiogram, or shock treated with vasopressors, documented anytime between Day 2 of treatment until discharge. Secondary outcomes included recurrent fever (after Day 2), use of other therapies (second dose of IVIG, glucocorticoids in those in the IVIG alone group, or biologics), and length of ICU stay. Multiple baseline variables were combined to develop a propensity score on study patients, then those treated with IVIG plus glucocorticoids were propensity score matched 1:1 with those receiving IVIG alone and the outcomes assessed with regression analyses.

A total of 518 patients with MIS-C received an immunomodulatory treatment. The median age of these children was 8.7 years, 58% were male, 75% were previously healthy, and 9 died. The most common initial treatments (on Day 0) were IVIG alone in 192 (37%) and IVIG plus glucocorticoids in 157 (30%); 34 patients received a biologic on Day 0 and were excluded from the analysis. Outcomes were compared in 206 patients (103 treated with IVIG plus glucocorticoids and 103 who received IVIG alone on Day 0) who could be propensity score 1:1 matched. Among these children, those receiving IVIG plus glucocorticoids had significantly less left ventricular dysfunction than those receiving IVIG alone (17% and 31%, respectively; risk ratio [RR], 0.56; 95% CI, 0.34, 0.94). Among those treated with IVIG plus glucocorticoids, 34% received adjunctive therapies vs 70% of those initially treated with IVIG alone (RR, 0.49; 95% CI, 0.36, 0.65). There were no significant differences between groups for rate of recurrent fever or length of ICU stay.

The authors conclude that among patients with MIS-C, initial treatment with IVIG plus glucocorticoids was associated with a lower risk of left ventricular dysfunction than treatment with IVIG alone.

Dr Bratton has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device....

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