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Page 8 of 11 Misra et al. Vessel Plus 2022;6:14 https://dx.doi.org/10.20517/2574-1209.2021.89

iii. New need for inotropic support;
iv. New rhythm changes;
v. New physical examination findings (i.e., murmur, gallop, jugular venous distension, hepatomegaly);
2. High sensitivity troponin I level:
a. Baseline: upon admission (if not done in the emergency department);
b. Repeat daily while febrile;
c. Continue daily until down-trending × 2 days.
3. Echocardiogram:
a. Baseline: upon admission to the floor (if not obtained in the emergency department);
b. Repeat echocardiogram during hospital stay if:
i. Increase in troponin from baseline;
ii. Advancing therapies/persistent fever/rising inflammatory markers after IVIG;
iii. New need for inotropic support;
iv. New rhythm or EKG (ST/T wave) changes;
v. New physical examination findings (i.e., murmur, jugular venous distension, hepatomegaly, gallop).
c. Repeat prior to discharge if the previous echocardiogram was abnormal.

Post-discharge cardiology follow-up for MIS-C patients
General cardiac recommendations
1. Continue low dose aspirin till discontinued by Infectious Disease/Cardiology;
2. Avoid strenuous exercise/ competitive sports for 6 months or until permitted by Cardiology;
3. Call if there is any recurrence of fever or other symptoms.

Cardiology follow-up visits
1. First follow-up: 2 weeks after discharge from the hospital;
2. Second visit: 6-8 weeks from the discharge;
3. Then cardiology follow-ups at 6 months and one year from discharge (additional visits to be scheduled
depending on the clinical course at follow-up);
4. Cardiac MRI to be done 6-12 months after diagnosis in patients who required intensive care admission.

TREATMENT PROTOCOL
During the early phases of the pandemic, given the overlap of MIS-C symptoms with Kawasaki disease,
therapeutics consisted of IVIG and other immunomodulatory medications. In a survey of the International
Kawasaki Disease Registry, 53% of participating sites reported using IVIG for all patients regardless of
[28]
illness severity or symptoms; 64% of sites used steroids for critically ill patients . Other
immunomodulatory medications, including infliximab, tocilizumab, and anakinra, were used as well in
[28]
patients with refractory MIS-C .

In our institution, patients who have confirmed diagnosis of MIS-C received first-line therapy with IVIG
(2 g/kg IV infusion over 12-24 h) and aspirin (moderate dose 30-50 mg/kg divided q6H PO till afebrile for
2-3 days, then low dose aspirin 3-5 mg/kg to a maximum of 81 mg daily for 6-8 weeks). Patients who are
refractory to IVIG therapy (persistent fever 24-36 h after completion of IVIG infusion) or patients who
presented with severe hemodynamic instability received an additional (second-line) treatment with
Infliximab or Solumedrol. Infliximab (10 mg/kg) was used more commonly as a second-line choice during
[29]
the first wave of COVID19 and MIS-C, resulting in favorable outcomes . Currently, Solumedrol,
Infliximab and/or second IVIG infusion are considered second-line therapy at our center.