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COVID in Children & MIS-C

Jun 25 | 2:55 PM

After witnessing a surge in COVID cases followed by mucormycosis, we are now seeing an increase in multisystem inflammatory syndrome in children (MIS-C) cases. This autoimmune condition has been reported among children who had contracted COVID so is the new delta wave going bring surg in MIS-C? Let's understand all about it's diagnosis & management from an excellant panel in India

so uh dr garg um ever since this over started last year you know between the who and the tdc they have been uh different things put out as to how this infection is transmitted do we actually have a consensus now how is the virus transmitted and how as a pediatrician when patients come and ask you how how does this virus spread and you know what we can what can we do do you do we have one or two reasons or one or two modes of transmission of virus you know the virus spreads mainly between people who are in close contact with each other typically within one meter it is short range or a patient can be infected when aerosol or the droplet containing the virus are inhaled or come in contact with the eyes nose mouth while speaking while coughing while sneezing or while singing or while breathing so the viruses if it has a if it is a large it has large particles smaller particles large particles is like a droplet it will spread within one meter and the smaller particles they can they work like aerosols they can go to any distance if it's an open air so it is not necessary that you have to be in close contact or you have to be somebody has coughed and you have in contact it may there in that area if it is an s in an open area which if it's not breeze is not very fast it must stay there for hours so even if you pass through that you can come in contact so that is why it is suggested you must be a mask always and people have been it can also be people can also be infected by touching surfaces which haven't contaminated the virus well while you touch it and you touch your eyes nose and mouth but this formide transmission has according to series has come down very drastically it's not that much it's just saturated suggested you keep watching your hand sanitizing hand properly there haven't uh transmission as a about the from the fecal overload has been distracted but it's a lot of confirms but people are studying on it but it does not get transmitted to food water or swimming so in nutshell it is always through inhalation so always keep your this area covered and don't touch your hand even if it's important a lot of people keep adjusting mass keep tucking them and somehow it may get you that they get intact so if you either we are respect or if you're very expect you obviously not touch your eyes these are the way you can always protect yourself and these are the ways it spreads thank you let's move on to the next one this is to uh dr manon yes man what signs and symptoms would alert you that this is a probable case of kovid19 and not the seasonal flu we are going to enter now the post training control what signs and symptoms and if you know considered more pediatricians would be doing a virtual consult so how are you going to be able to on on a virtual construct decide that this is you know most likely covet 19 and uh i may need to do these relevant tests or how are you going to counsel the parent yeah thank you man so covet 19 can present in any form from being an asymptomatic infection to having a whole gamut of fever and form and headache and running pose and foot pain and diagnose that's a typical question but i'll try to answer it in a step by step-by-step so the first thing is history if there is a history of contact my first suspicion should be supposed to be anybody who has had goals in the family or in the contact of the child i was going from literature trying to find out the differences between the symptoms of 419 versus 15 in terms of influenza 8 and certain points i found out were very relevant i thought i shared with you symptoms like running foreign are more commonly seen in influenza than in 4 19 children fever is more commonly seen in forward 19. the incubation period of influenza a is lesser than that of over 19. so if somebody has a deeper a headache a diarrhea vomiting and a history of contact with the kids if there is no history of compact and the kind foreign symptomatic children they're more likely to could be x1 n1 or influenza 8 but nevertheless you know something which we can talk academically but on ground practically every but still i would test for full rpt according to the diagnosis given by the wh so you know unless truth otherwise as long as the pandemic is there at the moment the who says that yes you should test everybody but then figure symptoms go more in favor of influenza a and m in the early stages particularly in small children especially if they come in with a high fever or something like that you know yes yes the influenza season we were seeing children coming with 100 and 304 fever in the first 24 hours yes yes basically now in the next few months of the post post uh the monsoons i think every fever patient that's what was happening even before that every fever child we would first think of corbett before and things like dengue and things were missed for quite a while uh moving on to our next question uh very often parents ask you you know whether somebody with mild symptoms or somebody who was asymptomatic but positive on on testing whether they can spread the illness these are a frequently asked question by parents and also is there any kind of marker to say or any kind of symptom which of the child presents which which will sort of point you to a direction that this child may develop a more severe infection dr bondra yes children who have mild symptoms can also transmit the infection and in fact even children who are asymptomatic may also transmit the infection the transversability would depend on the various mutants of kobit 19 and as we know the delta variant is a highly transmissible covet 19 variants the risk factors for severe disease i would take it as infantry in fact we have many children or infants who come with myocarditis and in a state of shock so infancy is one risk factor obesity is another risk factor and especially the obese adolescent they are at risk for a more severe infection and children with co-morbidities like a chronic kidney disease a chronic heart disease or a genetic disorder would be at a higher risk for a severe disease the next question is for you a child you've been called to ask about you know somebody with very high unremitting fever for 48 hours other than the rtpcr for covet is there are there any other tests that you do to rule out other what we call puos so yes uh when a child comes with fever for 48 hours uh often it is not uh i mean you can't really tell just like looking at the child whether the child has covered or not so depending on the season like right now with so many covets happening you have to think of forward in every child but you have to keep your mind open to other possibilities as well of other diagnosis so you would be thinking of other common infections which are not uncommon which are still happening in spite of covid with covet so you have children who have had coveted and had typhoid or parathyroid infections and so many other things so you have to be open so yes you asked whether you would do some other tests apart from rtpcr yes so you would do the usual investigations that i i mean anyone would do and i would ask for cbc a crp and blood culture at the least for a child who has fever and if you have any other focus you would look for some more specific investigations like x-rays or something like that as far as the rtpcr is concerned for many other investigations sometimes we say wait for two days let's see how the fever responds and then do the test do the cultures of crt but go with if you are actually suspecting proven it's better to do the rt pcr earlier so the chances of getting a positive rtpc are much higher in the early days the first second third days of fever rather than after the day five day six so you have to be open and you have to be sort of aware or have the options of all infections open with when you're approaching such a child yeah so would you would you actually say that you would first do an rtpcr on the day one or day two of illness and then do the blood test later if that comes as negative do you think or would you sort of do all of it together so i don't think there's an actual prescription as there but what i usually do is if i'm suspecting covet and as has been already mentioned you suspect governor and everyone in the season not now now but maybe a month back we were suspecting for it in everyone so you would do rt pcr right on the day one and i would wait for another two days before ordering the test unless the child is really safe okay let's move on so again namit what are the treatment options you know now we've gone through the whole cycle of treatment of kovet with drugs coming in coming out what are the treatment options for a child who you know on who's quite unwell on day four or day five gets admitted and if you have a child with my with mild symptoms what would you advise the parents so luckily for us most of the children and 90 of them have mild symptoms so most of them would only need need symptomatic treatment which is basically paracetamol if they have fever good hydration maybe sometimes some supportive treatments symptomatic treatment up and all and most of the children would not need anything more than that there would be a small fraction of children who would be sick enough who would not be taking orally enough or who would have some underlying problems and would need hospitalization but that is and we have all seen this in the last few months that this is a very small group of patients these patients would need to be treated on an individual basis depending on their underlying problem or the symptoms but by and large most of the patients would not need in specific medication most of the children would not need antivirals most of the children would not need steroids and just symptomatic treatment would suffice for 90 percent or probably even 95 percent of them the recent guidelines which have come out from the by the government of india uh are even more categorical saying there is no role of render severe mistake so it has it has actually been put to rest there's no rule of steroids will have some role but only in the very severe or some moderately severe cases but again most of them just symptomatic treatment nothing else but when if they're admitted when do you think you would you would think about starting steroids so uh covet acute covalent infection i can't recall needing steroids for any child except the ones who have been on ventilator so children with severe lung infection is a definite indication for steroids children who come in shock would need steroids but that is acute covet most of the steroids we have used has been which is a different thing because in the last couple of months when our numbers were very high and you know in most platforms you were of whatsapp groups and there were lots of these questions about the child is about fever for 10 days 12 days 14 days should we give a course of steroids would you agree so uh so i think the guidelines too have sort of uh turned around and sort of hinted towards the use of steroids earlier and then went back again as a general rule i don't think there is a role of steroids there might be a role for some very specific patients who have high grade fevers persisting beyond seven days uh but that that cannot come and that shouldn't go out as a message to people like life that you need steroids if your viewers are persisting you know with with all the media and everybody talking about the third wave and the third wave going to be affecting me children because this is a group that's not going to be vaccinated we're often asked you know how we're going to protect these children in the coming months what do we have to do to give you know anything they're not going to school are we going to lock them up at home how are we how are the how do we counsel these parents so this other school closer children are will meet their friends some family member is dying so they're neat they're the financial law parents have lost the job so everything is putting on the child's mind even in a smaller child understand there's something wrong with the family and they don't sleep they don't eat or they eat too much they put on weight there's a they always clash with the parents with the children that's going on before also not that it doesn't feel more so i would suggest them as a rule i tell them to be calm and proactive proactive means they are watching the child is watching that something which is abnormal they can stop or if they know the child is talking to the friend on phone they can stop it or they can control the screen time i have always been telling parents you know as long as you are in online classes there's no problem they shouldn't be allowed but after online classes they should avoid giving them laptop desktop tablets or mobile phone only thing they should allow them is to watch tv that too without netflix amazon or youtube because if they are watching tv program there has to be some ad there's a break in the concentration and they can do a lot of lot of things it's easy to tell them not to watch tv because they have to be occupied there are almost 16 are there to be a foreway so somehow i tell all the child my parents always make the routine as it was before the fandom if they're making that routine things will be much easier they should be involved children should be involved in the household and they should encourage to play chess or a carom some tasks where they learn cooking or some new hobby they should create so moving on to the last question in this segment that's the doctor and see a lot of these children you know the acute face of covid is over and then you're getting phone calls of children having these bouts of very often a dry irritating puff that is actually going on for fuel and a lot of children with skin rashes also all of different morphology and then they are labeled as mist or urticaria so do you need to treat all of this and how would you advise these parents especially for the cough thank you man it's actually a question which will have a very long answer but i'd like to answer in short so what you are referring to is probably called as a long table that is you know other symptoms like uh cough persisting cough for a long time skin rashes fatigue dysphonia chronic pain sometimes also cognitive impairment these things can persist for a long period of time so let me start with paul the probable uh pathogenesis of cough in you know long covered is probably because of the invasion of vagal sensory neurons or a neuroinflammatory response or both which can lead to peripheral and central hypersensitivity of the top pathways so this is probably the cause of thought now if we are talking of a mind talk which is not you know disturbing the child's day-to-day social activities we may not need to interpret much but then we don't know you know in some questions you know this is persistent this is hacking this is disturbing their day-to-day activities so what has been used is you know opioids they say they may be considered they may have been used but then your anti-inflammatory neuromodulator should also be considered in patients in whom this cough is uh becoming a problem you know day-to-day now when we talk about uh skin manifestations so i would i will not say you know minor skin manifestations doesn't matter you should understand what are the basic broad types of manifestations which are seen in long-term now we broadly divided into five categories and according to the skin manifestations we can also actually prognosticate you know how severe the problem is what is the possible survival in this patient you know depending on the skin manifestation so number one is the vaso-occlusive regions because these are the most similar kinds of regions which are seen in probate patients so they can be like you know they form particular or capital ischemia these are the these regions if they are seen in a patient of cobalt the prognosis is generally bad this is probably the only reason which can lead to a bad prognosis then we have a cycle of lesions thereafter we have uh [Music] to the cold but the presentation is like that exactly like that of the children so broadly these five kind of you know skin manifestations the next pitch is on misc now since most of the acute profit is over a lot of us having seeing children who probably have misc who probably don't have mric but labeled as mic so dr mantra what is this mift what is the cause and what is the actual incidence because if you the number of phone calls that you get you feel you realize that it's far more common or people assume so let me answer the last part it's not a very common disease and if you really review the literature uh the missing incidents in different papers would be anywhere between one is two thousand to one to ten thousand of children who had coveted so as a rough figure one in five thousand children i would say uh post covet can get a missy sort of presentation uh the full form of missy is multi system inflammatory syndrome in children and of course we must know the case definition of misc so there are two common uh case definitions of the who and the cdc both of which are fairly similar with some minor differences so to go on to the cdc uh definition of missy it's any fever three or more days in children between 0 to 19 years and it should have any of the two following of the five positive either skin or mucous membrane changes like you can have non purulent conjunctivitis or a strawberry tongue a hypotension or shock cardiac findings in terms of myocarditis or coronary dilatation evidence of coagulopathy or gi symptoms like vomiting diarrhea pain abdomen so any two of these five plus elevated inflammatory markers and no other obvious microbial cause example sepsis or a toxic shock syndrome and evidence of a recent covet 19 either an antigen or the serology positive or contact with a patient with covid19 so this is the case definition for missy as per who the cdc is also broadly similar except the age here is 0 to 21 years and any fever more than 24 hours so it's a more broader definition by cdc and inter inflammatory markers they also put neutrophilia lymphopenia and hypoalbuminemia and the systems that are involved in the cdc definition could also involve the kidneys the cns and also pulmonary the form of ards or pulmonary thromboembolism so this is the case definition not very common uh but we do see in tertiary care fairly large numbers now or at least till last month we saw fairly large numbers of missing uh in in tertiary care hospitals that's it thanks thank you dr so you know if somebody who's doing a busy um opd okay somebody was doing a busy opd you're seeing 20 25 vacations uh in a three hour slot uh when would you sort of what would you what symptoms would alert that you know this child needs a bit more evaluation and maybe maybe this child has a bias and what sort of investigations i know dr mantra said a bit about it but what investigation would you would you do at that stage as an outpatient to help ruin the diagnosis yeah thank you man dr bhantra has already covered the definition of mrisc and it's very very clear as given by the whole but one point is very important any fever in which any other cause is not explainable i think that should be the first one you know wherein you are able to pick up an alternative diagnosis that should be the first cause of fear of secondly if there is a history of covet in the patient or there is a history of contact of the patient with a case of clothing that is the second thing a very high grade fever in a child who has been in a family who has had children and you're not able to pinpoint any other diagnosis you know i and there is a rash along with that you know i would be very alert this could be misc and the investigations which i would want to do you know is first the acute phase reactions i would ask for a cpc a crp esr maybe a pt dimer one of these in any case if a child is so sick that i'm thinking that he's an misc he would rather advert and feed the child than you know [Music] a child who is sick has come in shock who is in hypotension you know that and has a history of contact with it and has fever pending and alternative diagnosis and in this pandemic i think it could be like dr bumper said the incidence is one in ten thousand or five thousand but the number of cases that we see in our tertiary care units sara has also seen probably i don't know if the incidence is really this less it could actually be more so maybe more data is required for that but then if you go by the classical w-2 definition it's not very difficult to pinpoint that [Music] because in one month you have seen about 12. so i'm sure everybody has seen 12 15 cases in a month so i don't know how much is the incidence and and i'm talking of patients who have had myocarditis dropping of patients who have come okay how do you differentiate them and because um you could have both there's there there is i think a paper presented my holy family where they presented a child who had karma tacky earlier and then misty this time around so are they the same thing you know both the seas have a common trigger that provokes an inflammatory gasket reaction and though have almost similar presentation but there are a lot of differences between the two one has to be very careful in diagnosing misc is you know is seen basically mostly kawasaki is seen mainly in the asian countries especially from japan and korea and whereas misc has been seen all across the globe but not seen it has not been reported from japan and south korea so and mia seen in children more than five years and kawasaki is seen releasing five years of age and also as i said this is the affluent i don't know why they write so because we have seen a lot of patients we have to arrange ivig for the patient and there are a lot of laboratory differences platelets and lymphocytes they both are usually low in misc so lipos lymphopenia is a very unique feature of misc and lymphofine and violet sections are seen it's also in hiv or also in metals but this is very unique because here the nlr ratio neutrophil lymphocyte ratio always more than one is to fight and although leukocyte is seen in both minus other than uh kawasaki disease but you know there's a marker like ferritin is so high in mic not in kawasaki bro cassette is usually increased in misc not in kawasaki number you've seen quite a few of these mic in the last say a couple of months or so um what would you watch out for the follow-up of these patients and how long would you please uh not follow up the follow-up would depend on the real or the type of misc so again uh if i might step back misc is is again a spectrum of disease it's not just one disease there are the different types of misc dr girl has just spoken about the kd form of the kawasaki disease form so it could be something very mild as what is known as a febrile inflammatory state or an empire state it could be a kawasaki disease phenotype it could be a kawasaki disease with shocks or kd shock phenotype or it could be a severe misc which presents with a severe systemic involvement like cardiovascular so again the follow-up could be varying between the various types of misc the most common type when we talk of misc and the most severe types we are usually talking of the myocarditis type where the heart is involved where the cardiac dysfunction is there and there is a very poor cardiac output these children usually come in shock they have very poor pulses but they respond dramatically you give them the immunosuppressive agents and they respond very well it is almost like the cerebral malaria we used to see the in our training days where you would give them medicines and the next day the child would be sitting up it's almost that dramatic response luckily most of the effects of misc either on the heart or on the vessels they show a very early resolution unlike kawasaki disease where the arterial the coronary artery information could go on for a very long time you would need a follow-up for a very long time in my sc as much as we know we know very little as of now as much as we know the resolution is quicker most of the heart functions the arterial changes in the kawasaki phenotype they resolve within two to three weeks so most of these patients should have a follow-up of at least two to three weeks and then you decide on the further follow-up depending on the type of underlying disease again i don't think i can give you one number as to how long you need to follow up but definitely for two weeks but basically it is that you can actually decide yes yes so one more question to dr girl this is basically you know uh with all the news channels everybody talking about this third wave you're gonna have so many children uh how do you think do we have the infrastructure to look after all these sick children with over in the coming months thank you doctor i would i still never believe the third way will come it is something like guessing whether it's going to you know getting in a pregnancy it's a boy or a girl so it's a 50 50 but i don't believe it is going to be corrupt but by this we are able to improve infrastructure that's one point and the government of india's numbers with guidelines away from the rural area city where they have expected with a ready with the say 50 to 60 at the icu beds with ventilation with oxygen ready and at this in mind in up and uh in nada it hasn't ripped it has they've been falling and we can see the change the garment is really geared up and it is it is making sure these they don't catch ketchup caught up like what happened in a second okay i think to just sort of sum up this was a real patient that i'm just going to tell you about the type of tele consultation early may when most patients didn't want to come to the hospital and a lot of us by not seeing preval patients uh on the first day so it's a five-year-old with five days of so the fever was ranging from hundred it started off with ninety nine hundred and every day she would call and say now it's a hundred and two right now the 125 over over five days every day it was rising and the interval between these episodes of fever was shot me so it did a count and the child actually was rtpcr positive exactly four weeks ago so this time the the tlc was eight thousand two hundred had a linklet count of 2.1 lakhs crv was 42 and the esr was 34. and the day we got got the test done the mother said the eye is also looking a little great so dr manon um what would be your differential diagnosis for for this case so given the history the kind of history has given me that he had moved about four weeks ago and he was just progressively writing so trying to fit it into the wr2 definition he were for more than three days yes it is here when the mother said the eyes are red that is also there i don't know whether there is any history of diarrhea or any gi symptoms because amongst the clinical symptoms what the who says fever with any of the two amongst the two just one symptom is there which is a conductive condition i can't find the second one there and there so that is one thing which is different but then i'll think of mls because equity phase reactants are also increased psr is high the cr3 is also high but a very important point is that you need to rule out any other possible cause you know which could lead to these symptoms so i would think you know it could be sepsis because of any other thing that could be entered into the uv it could be any other kind of communication so further investigations would also be required but definitely in this fandomage that is going on misc would be a top differential diagnosis then entrance or uti or any other uh little bit of tummy pain but no vomiting no diarrhea no nothing there is no vomiting on day 5 of day five of illness had some epigastric pain so epigastric pain without vomiting without diarrhea it doesn't fit into that triangle yesterday you know i just have one criteria that is a congenital condition the second criteria clinical criteria is missing but still you know one of the dd's would be minus c but then we'll need to look out for enteric or gastroenteritis or entropy like this or uti or any other any other cause any other focus of infection also needs to be well probably if you don't i got a test for the ketchup malaria peripheral smear and i'll get an urine routine if the urine culture this is minimalistic how reliable is this typhi dog no within a five days of fever it is just it's a quick method if you will get a response this result is 24 hours and that's all still you need a blood culture to conform there are a lot of patients who are covet positive and the diaphragm is a is a which hasn't found to be faster in those patients also so that's why i see if you look at this later here another ratio is to his foot lately it counts for 2.1 crp is not very it's marginally high but yeah his size is magically high total count is not increased much i would definitely look for thing which are which which is not probably forward so that's why every challenge you see blood has antibiotics okay so blood culture you'll probably do an x-ray you'll probably do a urine routine and culture uh to rule out other infections um dr mantha would you advise his mother to bring this child to hospital for hospitalization you know at least in the history or maybe other a physical examination i would like to know the hydration status of this child i would like to know what is his oral acceptance like is he accepting not very well i also like to assess the parental anxiety because parental anxiety is also a very important factor uh to decide hospitalization and another very important thing is the follow-up either in teleconsultation or as a physical consultation uh one thing i would like to point out is when you talk of crp it's very important to put the whether it's in milligram per deciliter or it's in gram per deciliter yeah yeah okay because sometimes in the highly sensitive crp the cutoff is 0.5 so then that becomes much much higher so i think with crt we just need to keep a little watch on what is the value attached to it so if there is a lot of parental anxiety i am not very sure of the follow-up whether they will be able to come i may admit this child or at least i would want to have serial tests for example you know if the uh c is progressively rising cultures come out to be negative i have no other cause for a cause for the fever and i start suspecting misty because of rising crp no obvious cause i would definitely admit this child having said uh that there are no other causes of fever not at this point of time uh but at the time of hospitalization and if it's in uh a moderately severe i put him as moderately severe uh under the red eye yes i would get an echo done uh to look for any coronary involvement yes i would do an echo yes this mother knew more about misc than i did so i did it admit this child we we got an echo done the echo was normal and thankfully for me uh within 24 hours i got a culture which says salmonella para-typhy in this place now we are going to be seeing a lot more of this we are going to have children with fever with typhoid with dengue and all these infectious diseases we have never done all these inflammatory markers and we have never done um ldh and ferritin who knows it may be quite high in in dengue it may be high in that point so you're going to be and you're going to have a lot of children with over the antibody uh positive uh when when you when you check them for for when you're when you have free when you're sort of investigating fever and there's a fan so you know sort of what if the cut off now uh namit how do you manage this this child if you're if you're saying that he could have he could have missed suppose he had uh changes in the in your echo and you have a culture which is paratypoid or typhoid how would you manage this trend so misc by definition everything else has to be excluded so if it is uh salmonella paratype growing on the blood culture this is para typhoid fever and this is not classical misc so this needs to be treated as a paratypoid infection the misc and the when i say misc i mean the severe forms of misc which are significant you need hospitalization even icu usually we see crps which are very very high hundreds 400 hundreds so really high say rts uh having said that i have come across at least two cases that i can recall off where the initial crps were very high the child had some myocardial dysfunction he started on uh ivig the child had a dramatic response and three days later we get a blood structure which is salmonella type so but again we did have a response to the ivig i think uh misc still is a clinical diagnosis if you think it's misc initially and the child is sick enough to warrant all the medications you would give all the treatment and as would sometimes happen your final diagnosis might happen in retrospect so like in this particular case that i'm describing we had a blood culture which was on day three day four which came back uh salmonella typhi positive but the child was already better so i don't really know whether the ivig helped this child with typhoid as well but we have to consider this child to be only typhoid and treat them as a typhoid infection because you're going to have places where they may or children may not be able to afford you know an older child with ivig that people may want to start steroiding i recognize yeah we just had a kid [Music] family had a quote on my challenge so she wanted she didn't understand the [Music] ultrasound but on that day somehow she would not satisfy the report she admitted in the hospital in other hospitals where she asked for a ultrasound the next day morning next morning it was very enthusiastic but the patient got better they revealed that thailand acute appendicitis so what i'm saying is that ivig can mask most times it's the anti-inflammatory marker because it works on the immunoglobulin has this action so human different masks many symptoms just be careful about using iv or even steroids because some places where if you have a 10 year old and you may not you know ivig is going to be quite expensive somebody might decide to give steel especially if you have changes in your echo so we will have to be a little careful now because you're going to get more and more children with forward antibody positive with fever with implements the markers because now we are doing inflammatory markers for every beaver so which we wouldn't do two years ago so but if we are suspecting misc and if it is a strong suspicion then i think it is justified because time becomes important if you have cardiac dysfunction then you would still give ivig you would still give steroids of antibiotics i suppose yes so again it has to be a general decision and yes we we are not doing i mean but yes i i must say the typhoid fever that we are seeing now which we thought was misc and these are two cases that i vividly remember had crps of 200 plus which i have never seen in thai fight till now this amount this number of crp rates just a point sir the very first paper which came from the united kingdom about misc uh where they initially described the first lot of patients they actually had four patients who had pain abdomen and they were operated and they found thing in the abdomen so it was a retrospective which is actually very very well described even patients undergoing surgeries actually i was reviewing the literature and what they say uh the pain abdomen that you get post covered is because uh in the prayers patches there is lymphoid hyperplasia so it generally tends to involve the ideal region number one number two uh there is the vasculitis of the mesenteric vessels and the the vasculitis of the micentric vessels can cause necrotizing lymphadenitis something like a kikuchi syndrome and it can also cause submucosal erythema and cirrhosal edema and erythema so there are findings on history pathology of children who have coveted and their presentation is like acute appendicitis so it's not like a clean appendix there are findings on histopathology that you find involving the ideal region and the lymph nodes and the vessels being inflamed the centric vessels and we have seen some children with severe which looked like an acute abdomen but we had very strong suspicion of misc because of some cardiac involvement as well and all the symptoms sort of disappeared with the treatment for misc so we have all the mix and matches of various permutation combinations of these symptoms absolutely and ultimately i think the clinician at the bedside is the best judge

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SPEAKERS

dr. Arvind Garg

Dr. Arvind Garg

National Instructor of PALS, NALS and a Consultant at Apollo Hospitals, Noida with over 30 years of medical practice.

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dr. Nameet Jerath

Dr. Nameet Jerath

Senior consultant, Pediatric Pulmonology and Critical Care at Indraprastha Apollo Hospitals, New Delhi with an experience of over 22 years.

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dr. Manish Mannan

Dr. Manish Mannan

HOD Paediatrics & Neonatology | Paras Hospitals | Gurgaon

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dr. Arvind Bountra

Dr. Arvind Bountra

Head Department Of Pediatrics | Max Smart Super Speciality Hospital | New Delhi

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dr. Saroja Balan

Dr. Saroja Balan

Neonatologist and Senior consultant | Indraprastha Apollo Hospitals | New Delhi

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dr. Arvind Garg

Dr. Arvind Garg

National Instructor of PALS, NALS and a Consu...

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dr. Nameet Jerath

Dr. Nameet Jerath

Senior consultant, Pediatric Pulmonology and ...

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dr. Manish Mannan

Dr. Manish Mannan

HOD Paediatrics & Neonatology | Paras Hospita...

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dr. Arvind Bountra

Dr. Arvind Bountra

Head Department Of Pediatrics | Max Smart Sup...

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dr. Saroja Balan

Dr. Saroja Balan

Neonatologist and Senior consultant | Indrapr...

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About Medflix

Medflix is a new platform by PlexusMD, India's most active and trusted doctor community. On Medflix, you can discover live surgeries, discussions, conferences and courses from some of the top doctors and institutions across the world. Join clubs in your areas of interest and access hundreds of amazing live discussions everyday.