Description:

Based on CRF on https://isaric.org/research/covid-19-clinical-research-resources/multisystem-inflammatory-syndrome-mis-c/ This Case Report Form (CRF) has been developed by ISARIC in cooperation with WHO's working group (https://www.who.int/news-room/commentaries/detail/multisystem-inflammatory-syndrome-in-children-and-adolescents-with-covid-19) to use as a standalone CRF for children and adolescents presenting with syndrome of suspected Multisystem Inflammatory Syndrome (MIS-C). Preliminary case definition Children and adolescents 0–19 years of age with measured or self-reported fever ≥ 3 days AND two or more of the following: a) Rash or bilateral non-purulent conjunctivitis or muco-cutaneous inflammation signs (oral, hands or feet) b) Hypotension or shock c) Features of myocardial dysfunction, or pericarditis, or valvulitis, or coronary abnormalities (clinical features, ECHO findings, or laboratory markers such as elevated Troponin/NT-proBNP) d) Evidence of coagulopathy (such as abnormal PT, PTT, elevated d-Dimers) e) Acute gastrointestinal problems (such as diarrhoea, vomiting or abdominal pain) AND Elevated markers of inflammation such as ESR, C-reactive protein or procalcitonin AND No other obvious microbial cause of inflammation, including bacterial sepsis, staphylococcal or streptococcal shock syndromes AND Evidence of current or previous COVID-19 (RT-PCR, antigen test or serology positive) or likely contact with patients with COVID NB Consider this syndrome in children with features of typical or atypical Kawasaki disease or toxic shock syndrome. This Module is to be completed when multisystem inflammatory syndrome is suspected, on admission or in-patients.

Link:
https://isaric.org/research/covid-19-clinical-research-resources/multisystem-inflammatory-syndrome-mis-c/
Keywords:
  1. 7/29/21 7/29/21 -
  2. 7/30/21 7/30/21 -
  3. 8/3/21 8/3/21 - Sarah Riepenhausen
Copyright Holder:
ISARIC on behalf of Oxford University
Uploaded on:

August 3, 2021

DOI:
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License :
Creative Commons BY-SA 4.0
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Multisystem inflammatory syndrome (MIS) in children and adolescents temporally related to COVID-19

MODULE 1: PRESENTATION/ADMISSION CASE REPORT FORM

Participant Identification
Demographics, complete when MIS is first suspected
Sex at Birth
Year
months
Onset of current illness and vital signs, complete when MIS is first suspected
°C
beats/min
breaths/min
mmHg
mmHg
Dehydration
Capillary refill time >2 seconds
Oxygen saturation
%
Conscious state
mm
cm
kg
Possible signs and symptoms of multisystem inflammatory syndrome, complete when MIS is first suspected
Fever
days
Rash
Bilateral conjunctivitis
Oral mucosal inflammation signs
Peripheral cutaneous inflammation signs (hands or feet)
Hypotension (age-appropriate)
Tachycardia (age appropriate)
Prolonged capillary refill time
Pale/motted skin
Cold hands/feet
Urinary output <2mL/kg/hr
Chest pain
Tachypnoea (age appropriate)
Respiratory distress
Abdominal pain
Diarrhoea
Vomiting
Other signs and symptoms
Cough
Sore throat
Runny nose
Wheezing
Swollen joints
Cervical lymphadenopathy
Joint pain (Arthralgia)
Muscle aches (Myalgia)
Skin ulcers
Fatigue / Malaise
Seizures
Headache
Hypotonia/floppiness
Paralysis
Irritability
Photophobia
Hyposmia/Anosmia (loss of smell)
Hypogeusia (loss of taste)
Not able to drink
Bleeding (Haemorrhage)
Recent history
Has the child been admitted to hospital in the last 3 months?
If yes, was it related to this illness episode or for the same or similar problems?
History of COVID-19 infection in the previous 4 weeks prior to current illness?
History of any respiratory infection in the previous 4 weeks prior to current illness?
Any household member (or other contact) with comfirmed COVID-19 in previous 4 weeks?
Past history of Kawasaki disease?
Family history of Kawasaki disease?
Co-morbidities, past history (complete when MIS is first suspected)
Inflammatory or rheumatological disorder
Hypertension (age appropriate)
Other chronic cardiac disease
Asthma
Tuberculosis
Other chronic pulmonary disease
Diabetes
Malignant neoplasm
Asplenia
Congenital or acquired immunesuppression
Chronic kidney disease
Chronic liver disease
Chronic neurological disorder
Hematologic disorder
HIV
Other comorbidity
Pre-admission and chronic medication: Were any of the following taken within 14days of admission (complete when MIS is first suspected)?
Non-steroidalanti-inflammatory (NSAIDs)
If yes, specify route:
Steroids
If yes, specify route:
Antibiotics
If yes, specify route:
Any other medication
If yes, specify route:
If yes, specify route:
If yes, specify route:
Laboratory results (complete with results of tests ordered at the time MIS is first suspected) (* record units if different from those listed) Record the worst value between 00:00 to 24:00 on day of assessment (if Not Available write ‘N/A’):
g/L
Haemoglobin (g/L) measurement not done?
x10^9/L
Total WBC count (x10^9/L) not done?
x10^9/L
Neutrophils (x10^9/L) measurement not done?
x10^9/L
Lymphocytes (x10^9/L) measurement not done?
%
Haematocrit (%) measurement not done?
x10^9/L
Platelets (x10^9/L) measurement not done?
APTT/APTR measurement not done?
sec
PT (seconds) measurement not done?
INR measurement not done?
g/L
Fibrinogen (g/L) measurement not done?
ng/mL
Procalcitonin (ng/mL) measurement not done?
mg/L
CRP (mg/L) measurement not done?
umol/L
Creatinine (umol/L) measurement not done?
mmol/L
Sodium (mmol/L) measurement not done?
mmol/L
Potassium (mmol/L) measurement not done?
mmol/L
Urea (BUN) (mmol/L) measurement not done?
mmol/L
Glucose (mmol/L) measurement not done?
pg/mL
Pro-BNP (pg/mL) measurement not done?
ng/mL
Troponin (ng/mL) measurement not done?
U/L
Creatine kinase (U/L) measurement not done?
U/L
LDH (U/L) measurement not done?
Triglyceride measurement not done?
U/L
ALT/SGPT (U/L) measurement not done?
umol/L
Total bilirubin (umol/L) measurement not done?
mm/hr
ESR (mm/hr) measurement not done?
mg/L
D-Dimer (mg/L) measurement not done?
pg/mL
IL-6 (pg/mL) measurement not done?
pg/mL
IL-10 (pg/mL) measurement not done?
U/L
AST/GOT (U/L) measurement not done?
g/dL
Albumin (g/dL) measurement not done?
mmol/L
Lactate (mmol/L) measurement not done?
ng/mL
Ferritin (ng/mL) measurement not done?
Imaging and pathogen testing (complete when results of tests ordered at the time MIS is first suspected are available)
Chest X-ray/CT performed
ECG performed?
Echocardiography performed
If yes, features of myocardial dysfunction?
If yes, features of pericarditis?
If yes, features of valvulitis?
If yes, features of coronary abnormalities?
Other cardiac imaging performed?

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