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Mucocutaneous Manifestations of Multisystem Inflammatory Syndrome in Children During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What were the mucocutaneous findings in hospitalized patients with multisystem inflammatory syndrome in children (MIS-C) during the peak incidence of coronavirus disease 2019 (COVID-19) in New York City in 2020?

Findings  This case series included 35 hospitalized children who met definitional and/or epidemiologic criteria for MIS-C, 83% of whom exhibited mucocutaneous symptoms that lasted from hours to days. Conjunctival injection, palmoplantar erythema, lip hyperemia, periorbital erythema and edema, strawberry tongue, and malar erythema were the most common findings.

Meaning  This study suggests that mucocutaneous findings, while polymorphous and transient, may aid in the recognition of MIS-C.


Importance  To date, no study has characterized the mucocutaneous features seen in hospitalized children with multisystem inflammatory syndrome in children (MIS-C) or the temporal association of these findings with the onset of systemic symptoms.

Objective  To describe the mucocutaneous findings seen in children with MIS-C during the height of the coronavirus disease 2019 (COVID-19) pandemic in New York City in 2020.

Design, Setting, and Participants  A retrospective case series was conducted of 35 children admitted to 2 hospitals in New York City between April 1 and July 14, 2020, who met Centers for Disease Control and Prevention and/or epidemiologic criteria for MIS-C.

Main Outcomes and Measures  Laboratory and clinical characteristics, with emphasis on mucocutaneous findings, of children who met criteria for MIS-C. The characterization of mucocutaneous features was verified by 2 board-certified pediatric dermatologists.

Results  Twenty-five children (11 girls [44%]; median age, 3 years [range, 0.7-17 years]) were identified who met definitional criteria for MIS-C; an additional 10 children (5 girls [50%]; median age, 1.7 years [range, 0.2-15 years]) were included as probable MIS-C cases (patients met all criteria with the exception of laboratory test evidence of severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] infection or known exposure). The results of polymerase chain reaction tests for SARS-CoV-2 were positive for 10 patients (29%), and the results of SARS-CoV-2 immunoglobulin G tests were positive for 19 patients (54%). Of the 35 patients, 29 (83%) exhibited mucocutaneous changes, with conjunctival injection (n = 21), palmoplantar erythema (n = 18), lip hyperemia (n = 17), periorbital erythema and edema (n = 7), strawberry tongue (n = 8), and malar erythema (n = 6) being the most common findings. Recognition of mucocutaneous findings occurred a mean of 2.7 days (range, 1-7 days) after the onset of fever. The duration of mucocutaneous findings varied from hours to days (median duration, 5 days [range, 0-11 days]). Neither the presence nor absence of mucocutaneous findings was significantly associated with overall disease severity.

Conclusions and Relevance  In this case series of hospitalized children with suspected MIS-C during the COVID-19 pandemic, a wide spectrum of mucocutaneous findings was identified. Despite their protean and transient nature, these mucocutaneous features serve as important clues in the recognition of MIS-C.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: October 16, 2020.

Published Online: December 9, 2020. doi:10.1001/jamadermatol.2020.4779

Corresponding Author: Vikash S. Oza, MD, The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, 240 38th St, 11th Floor, New York, NY 10016 (vikash.oza@nyulangone.org).

Author Contributions: Dr Oza had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Mr Young and Dr Shaw contributed equally to this manuscript.

Concept and design: Young, Shaw, Alperin, Orlow, Kahn, Oza.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Young, Shaw, Betensky, Kahn.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Young, Shaw, Shah, Betensky.

Administrative, technical, or material support: Shaw, Noor, Alperin, Ratner, Orlow.

Supervision: Noor, Alperin, Ratner, Orlow, Betensky, Shust, Kahn, Oza.

Conflict of Interest Disclosures: Dr Ratner reported receiving personal fees from and serving as a consultant for Pfizer outside the submitted work. Dr Orlow reported serving on the board of directors for Almirall S.A. Dr Oza reported receiving personal fees from Pfizer Consulting in the field of atopic dermatitis education and from Regeneron-Sanofi Pediatric Advisory Board dupilumab and a grant from Pfizer Grant: Educational Support for Primary Care Provider Management of Pediatric Atopic Dermatitis: A Health Literacy-Informed Approach outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the parents for granting permission to publish photographs of their children in the figures.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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