Emergency Department, ICU and Inpatient Clinical Pathway for
Evaluation of Possible Multisystem Inflammatory Syndrome (MIS-C)

Clinical/Historical Features
  • Rash
    • Polymorphic, maculopapular, petechial, NOT vesicular
  • GI Symptoms
    • Diarrhea, abdominal pain, vomiting
  • Extremity changes
    • Erythema and edema of the hands and feet in acute phase
  • Oral Mucosal Changes
    • Erythema and cracking of lips, strawberry tongue, and/or erythema of oral and pharyngeal mucosa
  • Conjunctivitis
    • Bilateral bulbar conjunctival injection without exudate
  • Lymphadenopathy
    • Cervical > 1.5 cm, unilateral
  • Neurologic Symptoms
    • Headache, irritability, lethargy, AMS
  • Epidemiologic Link to COVID
    • Patient with history of COVID disease or close contact with known Positive COVID case in past 4 weeks, or person placed in quarantine
Evaluation for Possible MIS-C in a stable patient
Suspected MIS-C with Shock
Fever/history of fever ≥ 38.0°C for ≥ 3 days
≥ 2 Clinical /Historical Features

Review Kawasaki Pathway
Fever/history of fever ≥ 38.0°C for ≥ 1 day
Evidence of myocardial dysfunction or
Hypotension/vasopressor requirement
≥ 2 Clinical/Historical Features
Initial Laboratory Testing
  • Other testing as clinically indicated to identify cause of fever, based on clinical features
  • ED Sepsis Pathway — Use ED Sepsis Order Set
  • Additional Diagnostic Laboratory Studies
    • Add COVID PCR, RRP, Troponin, BNP, D-dimer, Ferritin, Save Our Specimen, ECG
  • Fluid Resuscitation, Vasopressors
  • Antibiotics
  • Echo as clinically indicated
Labs and Physical
Exam Reassuring
Labs or exam concerning but inconsistent with MIS-C
  • CRP ≥ 3 mg/dL   and/or
  • ESR ≥ 40 mm/hr
  • AND
  • Lymphopenia < 1k   or
  • Thrombocytopenia < 150k   or
  • Na < 135   or
  • Abnormal creatinine for age
Admit to Inpatient
Consider Further Evaluation
  • Additional ancillary labs:
    • Troponin, BNP, EKG
    • Save our specimen
  • Cardiology Consultation if:
    • For review of abnormal ECG
    • Abnormal BNP, troponin
    • Concerns on PE
  • Consider culture, antibiotics
  • Tolerates PO
  • Reassuring PE
  • PCP follow-up 24-48 hrs

Guidance is based on expert consensus derived from a small number of reported cases and extrapolated from the related syndromes Kawasaki Disease/Kawasaki Shock Syndrome. As this guidance will evolve, consider ID, Rheumatology, Dysregulated Immune Response Team and Critical Care Medicine consultation for individualized recommendations for suspected cases.

Posted: May 2020
Revised: May 22, 27, 2020; June 9, 2020; July 2, 2020, July 8, 2020
Authors: D. Corwin, MD; K. Chiotos, MD; J. Lavelle, MD; S. Swami, MD; J. Burnham, MD; H. Bassiri, MD; A. John, MD; F. Balamuth, MD; K. Cohn, MD; M. Blackstone, MD; J. Callahan, MD; V. Kampalath, MD; R. Rempell, MD; M. Elias, MD; T. Giglia, MD; C. Witmer, MD; D. Davis, MD; C. Kerman, MD; D. Whitney, MD; E. Behrens, MD; D. Teachey, MD; C. Jacobstein MD