Assessing pattern of the pediatric multisystem inflammatory syndrome (PMIS) in children during COVID-19 infection: Experience from the emergency department of a LMICs tertiary care hospital. 

Assessing pattern of the pediatric multisystem inflammatory syndrome (PMIS) in children during COVID-19 infection: Experience from the emergency department of a LMICs tertiary care hospital. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing pattern of the pediatric multisystem inflammatory syndrome (PMIS) in children during COVID-19 infection: Experience from the emergency department of a LMICs tertiary care hospital. Surraiya Bano, Saleem Akhtar, Iqra Anis, Muhammad Tayyab Ihsan, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2544129/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Feb, 2024 Read the published version in BMC Pediatrics → Version 1 posted 13 You are reading this latest preprint version Abstract Background Pediatric multisystem inflammatory syndrome (PMIS) is a hyperinflammatory syndrome with multi organ involvement. In children, severe complications were reported with features similar to incomplete Kawasaki disease during later phases of COVID- 19 infection. Objectives This study aimed to determine the frequency, pattern of presentation, and significant laboratory parameters related to PMIS in children presenting to the emergency department during COVID − 19. Method This was a prospective observational study. Children (1 month − 16 years) with symptoms suggestive of PMIS were included. A predesigned questionnaire was used to collect data on demographics, presenting complaints, performing investigations, offering treatment, and the outcome during the emergency stay. Besides using descriptive statistics, the Mann-Whitney U test compared the in-hospital mortality with triage vitals to see any significant differences between Alive and Expired. The Chi-square test or Fisher exact test was used for categorical data to see the association. Result 56 patients, majority male (85.7%), were diagnosed with the pediatric multisystem inflammatory syndrome with a mean age of 7.67 ± 4.8 (ranging from 1 to 16 years). COVID PCR was positive in only 18% (10) patients, whereas COVID antibodies were positive in 78.6% (44). The main presenting complaints were related to respiratory 70% followed by neurological 57% and Gastrointestinal 54% with the common clinical sign of delayed capillary refill time (93%) and low volume pulses (89%). Out of 12 patients with negative COVID antibodies, 10(83.3%) patients tested PCR positive, whereas only 2 (16.7%) patients had both antibody body and PCR negative. Based on the multivariate binary regression model indicated that the risk for mortality was higher in patients with ED Stay of more than 4 Hours (OR = 5.4), a total hospital stays of more than five days (OR = 0.17, 95% CI: 0.02 to 0.64). Conclusion Most children with PMIS were found to have positive antibodies against COVID-19. An increased ED stay was associated with poor outcomes. Pediatric inflammatory syndrome COVID-19 Emergency Figures Figure 1 Introduction The 2019 novel coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARSCoV2) is a viral pandemic that spreading worldwide. During the early phase of the COVID-19 pandemic, children were thought to be less affected, with mild respiratory symptoms and low morbidity and mortality. 1, 2 As the pandemic progressed, several studies reported severe complications in children with features of significant inflammation, toxic shock syndrome, and clinical features similar to incomplete Kawasaki disease (K.D.). 3 In particular, a syndrome of hyperinflammatory process associated with fever emerged in the pediatric population with positive Covid-19 test results. 4 The syndrome was later described as Pediatric Inflammatory Multisystem Syndrome (PMIS) by the Royal College of Pediatrics and Child Health (RCPCH) and as Multisystem Inflammatory Syndrome in Children (MIS-C) by the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC). 5, 6, 7 PMIS or MISC were preliminarily defined as a hyperinflammatory syndrome with multiorgan involvement and clinical features that overlap with KD. 8 The cases of this hyper-inflammatory syndrome have similarities to ..K.D. and Toxic shock syndrome (TSS). 9 Severe cases have been reported to the Emergency department (E.D.) with shock and multiorgan failure. 9 - 12 Hence, it is treated as an inflammatory condition with multiorgan involvement significant data is lacking, especially from the E.R.. 10 To the best of our knowledge, limited data on PMIS associated with COVID-19 from developing countries is available. We conducted this study in ..E.D. of a tertiary care hospital. This study aims to determine the frequency, pattern of presentation and laboratory parameters in children presenting with pediatric multi system inflammatory syndrome (PMIS) to ..E.D. during the COVID -19 pandemic. Methods This prospective observational study was conducted in .E.D. of Aga Khan University Hospital (AKUH) Karachi from March 2020-September 2021. AKU’s ..E.D. is a 60 bedded emergency room with 17 dedicated pediatric beds. In our .E.D., we see around 15000 pediatric patients a year. AKUH receive patients from Sindh and neighboring provinces like Punjab, Baluchistan, and Khyber Pakhtunkhwa. All children (1 month to -16 years) with signs and symptoms suggestive of PMIS according to WHO preliminary definition criteria regardless of COVID-19 positive or negative. were included in the study. Predesigned questionnaire was used for data collection. Data were collected regarding patient demographics, presenting complaints, investigation performed, treatment offered and outcome during the emergency room stay. Statistical Analysis: Microsoft Excel Spreadsheet (2010) was used for data management & cleaning and then transported into SPSS-22 (IBM, IL, USA) for statistical analysis. The data were analyzed using descriptive statistics; results were reported as numbers with percentages for qualitative variables and expressed as mean ± standard deviation or medians with ranges for continuous variables. The Mann-Whitney U test compared the in-hospital mortality with triage vitals, e.g. (SBP & DBP, H.R., R.R.), to see any significant differences between Alive and Expired. For finding the association between the groups (alive/expired), the Chi-square test or Fisher exact test was used for categorical data. Continuous outcomes (if the normality assumption is satisfied) were compared using a t-test. a After selecting confounding indicators of the study, we carried out the univariate analysis, taking mortality as a dependent variable and selecting significant variables in the univariate model. Independent variables with a p-value of <0.2 were used in a multiple binary logistic regression model. We developed multivariate models using the stepwise backward likelihood function. In the multivariate models, the p-value of less than or equal to 0.05 was considered significant. The areas under each receiver operating characteristic curves (AUC of ROC curve) were calculated to compare the overall discriminatory power of different laboratory markers in predicting in-hospital mortality. Values of AUC higher than 0.8 were considered as good, between 0.6-0.8 as acceptable or moderate, and lower than 0.6 as poor to determine the threshold value of different clinical markers in terms of different sensitivities and specificities. Our primary endpoint was the in-hospital mortality rate. Results were reported as ODD Radio (OR) with a 95 % confidence interval. Results Total of 56 patients were diagnosed with pediatric multisystem inflammatory syndrome. The mean age of the patients was 7.67 ± 4.8 (ranging from 1 to 16 years). All age groups (infants, children and adolescents) were equally affected. There was a male pre dominance in our study(85.7%). Patient demographics are shown in Table 1 . Table 1 Descriptive & Baseline Characteristics of Pediatric multi system inflammatory syndrome Mean ± .D.S.D. (Range) Age years 7.67 (± 4.8) (1–16) Weight in Kg 22.46 (± 17.1) (3.5–82) Length of Hospital Stay (In Days) 7.14 (± 6) (1–30) Age Groups Percentage (%) Frequency (f) 1 Day to 1 Years 30.40% (17) 2–5 Years 19.60% (11) 6–10 Years 23.20% (13) 11–16 Years 26.80% (15) Gender Female 14.30% (8) Male 85.70% (48) . R.E.R. Stay Mean ± .D.S.D. (Range: Min-Max) 5.41 ± 3.10 (1.5 to 16.5 Days) =4 hours 75.00% (42) Hospital Stay Mean ± .D.S.D. (Range: Min-Max) 7.14 ± 5.97 (1to 30 Days) =5 Days 62.50% (35) Status Alive 82% (46) Expired 18% (10) The main presenting complaints were related to respiratory 70%, neurological 57%, Gastrointestinal 54%, and skin manifestations 34%. Delayed capillary refill time (93%), low volume pulses (89%) and tachycardia(60%) were the most common clinical signs suggestive of shock state. Non purulent conjunctivitis (16.1%), and Strawberry tongue were seen (28.6%) cases. Presenting complaints and examinations findings are shown in Table 2 . Table 2 Presenting complain and examination findings Mean ± .D.S.D. (Range) Percentage (%) Frequency (f) Presenting Complain Respiratory 70% (39) Gastrointestinal Symptoms (G.I) 54% (30) Skin Manifestations 34% (19) Neurological Symptoms 57% (32) Emergency Vitals Mean ± .D.S.D. (Range: Min-Max) SBP 86.96 (± 15.4) (50–110) DB 49.11 (± 12.5) (30–76) HR 137.29 (± 28.3) (84–221) RR 33.16 (± 9.8) (20–60) Tachycardia 60.70% (34) Temperature 37.3 (± 2.2) (27–40) GCS 13.05 (± 3.2) (3–15) Capillary Refill time (CRT) =2 sec 93% (52) Pulses Low 89% (50) Normal 11% (6) General Physical Examination Cervical lymph 10.70% (6) Conjunctivitis_Non_purulent 16.10% (9) Strawberry tongue 28.60% (16) Skin Manifestation 33.90% (19) Pedal edema 3.60% (2) Screening for COVID-19 was done in all 56 patients; initially, PCR were sent, and if PCR negative, covid antibodies were sent. COVID PCR was positive in only 18% (10) patients whereas COVID antibodies were positive in 78.6% (44). Out of 12 patients who had negative COVID antibodies, 10(83.3%) patients were tested PCR positive, whereas only 2 (16.7%) patients had both antibody body and PCR negative. D escriptive characteristics of Hematological, inflammatory biomarkers and biochemistry parameters. Shown in Table 3 Table 3 Hematological, inflammatory and biochemical markers in patients with PMIS Baseline and Demographics variables Mean ± .D.S.D. (Range) Inflammatory Markers CRP 135.37 (± 99.6) (0.37-383.59) ESR 46.09 (± 23.2) (2–74) Ferritin 2497.6 (± 3881.1) (76.4-17729) Ferritin 2497.6 (± 3881.1) (76.4-17729) LDH 945.22 (± 1652.4) (219-10176) Cardiac Marker Trop_I_ 25.06 (± 115.5) (0.01–739) Pro_BNP 38194 (± 79957.9) (75-376052) Ejection Fraction 52 (± 15) (6–71) Hematological Parameters HB 10.2 (± 1.7) (6.9–13.5) TLC 13.12 (± 6.7) (1.6–26.3) Neutrophil 69.11 (± 20.1) (10.7–94.4) Lymphocyte 23.73 (± 17.7) (3.3–83.7) Platelet counts 217.02 (± 160.6) (15–709) Bio chemistry Parameters PCT 34.01 (± 41.6) (0.12–100) NA 137.11 (± 9.1) (125–172) K 4.08 (± 1.4) (1.8–9.8) CL 102.75 (± 8.6) (92–139) BIC 18.94 (± 5.9) (5.1–30.7) lactate 4.65 (± 3.6) (0.7–14) Bun 25.56 (± 16.4) (5–94) Creatinine 0.81 (± 0.5) (0.3–2.4) Coagulation profile PT 18.77 (± 22.9) (10.1–170) APTT 41.49 (± 30.3) (24.7–170) INR 1.83 (± 2.3) (0.9–17) D DIMER 13.32 (± 11.8) (0.3–30) Antibody Non Reactive (12) 21.4% Reactive (44) 78.6% PCR Negative (46) 82.1% Positive (10) 17.9% Based on the multivariate binary regression model indicated that the risk for mortality was higher in patients with .E.D. Stay of more than 4 Hours (OR = 5.4, 95% CI: 1.27 to 22.93), a total hospital stay of more than five days (OR = 0.17, 95% CI: 0.02 to 0.64), hypotension at presentation (OR = 4.25, 95% CI: 1.02 to 17.69), hemoglobin level 322(OR = 23.5, 95% CI = 2.5 to 61.3), and Lactate Dehydrogenase (LDH) > 246 U/L (OR = 20.5, 95% CI = 3.85 to 53.6). (Table 4) Table:4 Univariate and multivariate binary regression for the prediction of mortality in PMIS Factors Univariate Multivariate OR [95% CI] P-value OR [95% CI] P-value Male gender 0.6 [0.1 -3.53] 0.572 ----- ----- Dialysis (Yes) 7 [1.37 -35.68] 0.019* ----- ----- Hypotension (Yes) 4.25 [1.02 -17.69] 0.047* 5.25 [2.78 -59.15] 0.027* Tachycardia (Yes) 6.22 [1.19 -32.68] 0.031* ----- ----- .I.G.I. Symptoms (Yes) 9 [1.05 -76.9] 0.045* ----- ----- ETT (Yes) 28.64 [3.26 -151.86] 0.002* ----- ----- FFP (Yes) 5.4 [1.27 -22.93] 0.028* ----- ----- Vitamin K (Yes) 9.14 [1.72 -48.66] 0.009* ----- ----- Norepinephrine (Yes) 8.27 [1.56 -43.81] 0.013* 0.91 [0.68 -12.73] 0.08 ED Stay >=4 Hours 5.4 [1.27 -22.93] 0.022* 15.75 [1.25 -198.5] 0.033* Hospital Stay >=5 Days 0.19 [0.04 -0.83] 0.028* 0.17 [0.02 -1.3] 0.088 Hemoglobin level (=35 sec 2.3 [0.56 -9.54] 0.251 ----- ----- Platelet level =322 ng/mL) 14 [10.6 -56.33] 0.017* 23.5 [2.5 -61.3] 0.011* Pro_BNP (>1000 pg/ml ) 9.82 [1.15 -83.91] 0.037* ----- ----- Troponin level (>0.006 ng/ml 3.39 [0.37 -31.33] 0.282 ----- ----- D-Dimer level (>0.5 μ/mL) 3.49 [1.54 -18.66] 0.032* 2.75 [1.86 -40.53] 0.046* LDH level (>246 U/L) 9 [2.85 -56.7] 0.045* 20.5 [3.85 -53.6] 0.024* .T.P.T. level (>12) 8.67 [1.59 -47.15] 0.012* ----- ----- INR level 11.2 [2.03 -61.89] 0.006* ----- ----- Lactate level (>=4 mmol/L) 1.29 [0.29 -5.68] 0.739 ----- ----- Abbreviations: C.I, Confidence interval, OR, Odd ratios Univariate and multivariate logistic regression for the prediction of mortality (International Normalized Ratio=INR, PT= prothrombin Time, ED= Emergency, LDH=Lactate dehydrogenase, BNP= B-type natriuretic peptide The ROC curves for predicting mortality are displayed in Fig. 1 . The calculated AUC values were as follows: 0.831 (95%CI: 0.684–0.978) for the LDH, 0.708 (95%CI: 0.508–0.908) for the ferritin level, 0.627 (95%CI: 0.394–0.859) for the D-Dimer, 0.815 (95%CI: 0.634–0.996) for the APTT, 0.737 (95%CI: 0.489–0.985) for the lactate Each model produced statistically significant AUCs with respectable and comparable values. The AUCs were compared, but no real differences were found. However, it might be argued that the LDH, ferritin, lactate, and D-Dimer provide the best discriminatory power. Discussion In this article, we report the data of 56 patients who came to Aga Khan University Hospital (AKUH). They were diagnosed with PMIS, fulfilling the inclusion criteria mentioned by RCPCH. 5 While there is a plethora of studies done on PMIS, this is the first study that highlights the cases coming to the. ED. in a developing country like Pakistan. In our study, children with a median age of 7.67 years were diagnosed with PMIS with male gender dominance of 85%. 70% of patients presented with respiratory complaints followed by 57% neurological. In a study done on children in Latin America, it was 3 years and, in a study, done in France and Switzerland, it was ten years. 16 , 17 There have been considerably more males diagnosed with MIS-C than women, and the same pattern was also found in our sample, hinting at some factor that puts this gender at a greater risk. 18 , 19 Another study in New York revealed that the majority of children diagnosed were aged between 6 and 12 years, 80% reported gastrointestinal symptoms, and 63% had cardiovascular symptoms associated with echocardiographic abnormalities and hypotension. Majority of children require intensive care treatment. 20 Gastrointestinal complaints were common in the expired group in our patient sample however, the most common patient complaint in our sample was respiratory complaints followed by neurological complaints. This is contrasting with a study done in the .U.S. across 26 states where the gastrointestinal involvement was 92% while those with respiratory symptoms were 70% of the total sample and another systematic review on MIS-C in which ⅘ of the sample had diarrhea and abdominal pain which was described so severe that patients were presumed to have appendicitis. 21 , 22 As we know that SARS-COV2 spreads through its effects on angiotensin converting enzyme receptors (ACE receptors) that are present throughout our body but especially in the lungs, which is why its main effects is on the lungs. More common .G.I. effects might be because of transmission of virus through GIT or feco-oral transmission due to the ACE2 receptors in intestines and this also explains the spread of disease in children considering their lack in hand hygiene, but they generally acquire a milder or asymptomatic disease due to their immature immune system. 23 More evidence suggests that this condition presents a few weeks after COVID infection in children when it is cleared from the upper respiratory tract, hence .G.I. symptoms being more common. 24 The covid screening was done in all patients; in most patients, positive serology was seen, while some also had a positive PCR. It is because the onset of this condition is after several weeks when the PCR is no longer positive and antibodies have been made. This is also consistent with most studies suggesting PMIS could be due to the antibodies made against the virus that might play a role in bringing the cytokine storm and result in a hyper inflammatory state. 28 A more severe case has also been associated with antibody-dependent enhancement in which a type of antibody is made which cannot neutralize the virus ultimately promoting virus growth. 29 Most of the sample population presented with abnormal ECG, which is one of the diagnoses for myocarditis since sinus tachycardia is one of the most common findings in myocarditis.25 and multiple studies have shown COVID-19. PMIS is associated with myocarditis-like symptoms presenting with arrhythmias. 26 , 27 Similarly, in our results, sinus tachycardia was the main finding, along with ventricular tachycardia. Due to this, almost all the patients in our population had delayed capillary refill time and had cardiac resynchronization therapy for less than 2 seconds. Research has shown that inflammatory markers, especially the ones indicating cardiac injury, including ESR, ferritin, LDH, fibrinogen, and CRP levels, were higher in patients meeting the PMIS criteria resulting from the pathogenesis. 29 In our study, increased stroponin, ferritin, INR, D-dimer, and Pro-BNP showed a higher mortality risk. Especially patients with LDH greater than were heavily associated with the expired group. In the current study, even though the number of patients who expired was not high after being admitted to the .ED. or the hospital, the expired group was associated with staying in the hospital for more than five days, increasing theirs by nine folds. This contrasts with studies with notably low expiry rates for patients with greater lengths of stay and admitted to the Intensive Care Unit. 21 , 22 Only the data from inside AKUH was used for this paper which limited the sample size. The method of collection and analysis did not compare people with different geographical or social background. Furthermore, for diagnosis of COVID-19, only throat PCR was used, as other methods, like stool PCR, were not available at the facilities. This method can be used to detect SARS-COV-2 after it has been cleared from the upper respiratory tract as discussed above. Conclusion Majority of the children with PMIS were antibody positive against COVID-19.Respiratory and gastrointestinal symptoms were the most common presenting complaints and majority of the patients were in shock like condition. Hypotension, low Hemoglobin, raised LDH and.Ferriten along with increased length of ED stay were associated with increase risk for mortality. Declarations Ethics approval and consent to participate: All methods were carried out according to “deleration of helesenki.” Ethical approval was obtained from Ethical Review Committee, Aga Khan University, Karachi Pakistan. Consent was waived from Ethical Review Committee, Aga Khan University, Karachi Pakistan. Consent for publication : Not applicable Availability of data and materials : The datasets used and/or analysed during the current study available from the corresponding author [email protected] on reasonable request. Competing interests: There are no competing interest Funding: No funding required Authors' contributions: SB & SA: Conceptualization, Supervision and Writing, revieing and editing. AR- Methodology & Analysis MT- Data Curation, Writing, revieing and editing. IA- Writing, revieing and editing. All author’s reviewed and approved final manuscript. Acknowledgements: Not applicable References Gudbjartsson DF, Helgason A, Jonsson H, et al. Spread of SARS-CoV-2 in the Icelandic population. N Engl J Med 2020;382:2302–15. Williamson E, Walker A, Bhaskaran K, et al. 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PMID: 32574284; PMCID: PMC7235428 Grama A, Căinap SS, Mititelu A, Blag C, Simu C, Burac L, Simionescu B, Mărgescu C, Sur G, Spârchez M, Bota M, Tănasă B, Pop TL. Multisystemic Inflammatory Syndrome in Children, A Disease with Too Many Faces: A Single-Center Experience. J Clin Med. 2022 Sep 6;11(18):5256. doi: 10.3390/jcm11185256. PMID: 36142902; PMCID: PMC9504807. Zhao Y, Yin L, Patel J, Tang L, Huang Y. The inflammatory markers of multisystem inflammatory syndrome in children (MIS-C) and adolescents associated with COVID-19: A meta-analysis. J Med Virol. 2021 Jul;93(7):4358-4369. doi: 10.1002/jmv.26951. Epub 2021 Apr 1. PMID: 33739452; PMCID: PMC8250955. Tahir F, Bin Arif T, Ahmed J, Malik F, Khalid M. Cardiac Manifestations of Coronavirus Disease 2019 (COVID-19): A Comprehensive Review. Cureus. 2020;12(5):e8021. Published 2020 May 8. doi:10.7759/cureus.8021. Most ZM, Hendren N, Drazner MH, Perl TM. Striking Similarities of Multisystem Inflammatory Syndrome in Children and a Myocarditis-Like Syndrome in Adults: Overlapping Manifestations of COVID-19. Circulation. 2021;143(1):4-6. doi:10.1161/CIRCULATIONAHA.120.050166 Whittaker E, Bamford A, Kenny J, et al. Clinical Characteristics of 58 Children With a Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2. JAMA. 2020;324(3):259-269. doi:10.1001/jama.2020.10369 Bustos B R, Jaramillo-Bustamante JC, Vasquez-Hoyos P, Cruces P, Díaz F. Pediatric Inflammatory Multisystem Syndrome Associated With SARS-CoV-2: A Case Series Quantitative Systematic Review. Pediatr Emerg Care. 2021;37(1):44-47. doi:10.1097/PEC.0000000000002306 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Feb, 2024 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Major revision 13 Jul, 2023 Reviews received at journal 11 Jul, 2023 Reviewers agreed at journal 22 May, 2023 Reviews received at journal 19 May, 2023 Reviewers agreed at journal 09 May, 2023 Reviews received at journal 02 Apr, 2023 Reviewers agreed at journal 28 Mar, 2023 Reviewers agreed at journal 28 Mar, 2023 Reviewers invited by journal 28 Mar, 2023 Editor assigned by journal 28 Mar, 2023 Editor invited by journal 08 Mar, 2023 Submission checks completed at journal 08 Mar, 2023 First submitted to journal 02 Feb, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2544129","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":181810027,"identity":"2347eee3-a1e6-4545-8cd5-ccf4250d032d","order_by":0,"name":"Surraiya Bano","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYNACAyCWADEqwEwIm0gtZ4jWAlPG2EaEFvkZuc8+/Cg4LM8g3fzswcd5dsYGB5gP3ubB56Qb6cYzewwOGzbIHDM3nLkt2czgAFuyNV4tEmnMDDwGhxkbJBLMpHm3MdsYHOAxk8anRX5GGjPjH4PD9g0S6d+keefUA7Xwf8OrheFGGjMz0JbEBokcoC0Nh4EO42HDq8XgzDNmZhmD9OQ2mTNlkjOOHTeWPMxmbDkHn8PagQ5788fatl+6fZvEh5pqw77jzQ9vvMHnMAhoZmCDs5kJKweBOuKUjYJRMApGwcgEAGVqQ/NNv5+7AAAAAElFTkSuQmCC","orcid":"","institution":"Aga Khan University Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Surraiya","middleName":"","lastName":"Bano","suffix":""},{"id":181810028,"identity":"a634022c-196f-4691-aee8-b513196397a8","order_by":1,"name":"Saleem Akhtar","email":"","orcid":"","institution":"Aga Khan University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Saleem","middleName":"","lastName":"Akhtar","suffix":""},{"id":181810029,"identity":"af45a5d6-a7eb-4be1-9031-b4c135e085ba","order_by":2,"name":"Iqra Anis","email":"","orcid":"","institution":"Aga Khan University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Iqra","middleName":"","lastName":"Anis","suffix":""},{"id":181810030,"identity":"e5701d08-f287-42ea-b6b9-01b0c8b1f033","order_by":3,"name":"Muhammad Tayyab Ihsan","email":"","orcid":"","institution":"Aga Khan University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Tayyab","lastName":"Ihsan","suffix":""},{"id":181810031,"identity":"8c0a3d18-3331-4d2e-bab1-199c75b12777","order_by":4,"name":"Ahmed Raheem","email":"","orcid":"","institution":"Aga Khan University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Raheem","suffix":""}],"badges":[],"createdAt":"2023-02-02 18:59:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2544129/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2544129/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-024-04572-x","type":"published","date":"2024-02-03T15:01:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":34232673,"identity":"a0f09630-99fd-4400-81b1-2b53b1daa2d3","added_by":"auto","created_at":"2023-03-14 14:19:36","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":252609,"visible":true,"origin":"","legend":"\u003cp\u003eThe ROC curves for predicting mortality\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-2544129/v1/e60945ccfa8141e791df66dc.jpeg"},{"id":50674281,"identity":"28213353-47d4-47a0-b99d-6429186a10ff","added_by":"auto","created_at":"2024-02-05 15:10:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":574063,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2544129/v1/2ad061f1-80e5-4dec-b0d8-fb6784418ee6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing pattern of the pediatric multisystem inflammatory syndrome (PMIS) in children during COVID-19 infection: Experience from the emergency department of a LMICs tertiary care hospital. ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe 2019 novel coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARSCoV2) is a viral pandemic that spreading worldwide.\u0026nbsp;During the early\u0026nbsp;phase of the COVID-19 pandemic, children were thought to be less affected, with mild respiratory symptoms and low morbidity and mortality. \u003csup\u003e1, 2\u0026nbsp;\u003c/sup\u003eAs the pandemic progressed, several studies reported severe complications\u0026nbsp;in children with features of significant inflammation, toxic shock syndrome, and clinical features similar to incomplete Kawasaki disease (K.D.). \u003csup\u003e3\u0026nbsp;\u003c/sup\u003eIn particular, a syndrome of hyperinflammatory process associated with fever emerged in the pediatric population with positive Covid-19 test results.\u003csup\u003e4\u003c/sup\u003e The syndrome was later described as Pediatric Inflammatory Multisystem Syndrome (PMIS) by the Royal College of Pediatrics and Child Health (RCPCH) and as Multisystem Inflammatory Syndrome in Children (MIS-C) by the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC). \u003csup\u003e5, 6, 7\u0026nbsp;\u003c/sup\u003ePMIS or MISC were preliminarily defined as a hyperinflammatory syndrome with multiorgan involvement and clinical features that overlap with KD.\u003csup\u003e8\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe cases of this hyper-inflammatory syndrome have similarities to ..K.D. and Toxic shock syndrome (TSS).\u003csup\u003e9\u003c/sup\u003e Severe cases have been reported to the Emergency department \u0026nbsp;(E.D.) \u0026nbsp;with shock and multiorgan failure.\u003csup\u003e9\u003c/sup\u003e-\u003csup\u003e12\u0026nbsp;\u003c/sup\u003eHence, it is treated as an inflammatory condition with multiorgan involvement significant data is lacking, especially from the E.R..\u003csup\u003e10\u003c/sup\u003e To the best of our knowledge, limited data on PMIS associated with COVID-19 from developing countries is available. We conducted this study in ..E.D. of a tertiary care hospital. This study aims to determine the frequency, pattern of presentation and laboratory parameters \u0026nbsp;in children presenting with pediatric multi system inflammatory syndrome (PMIS) to ..E.D. during the COVID -19 pandemic. \u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis prospective observational study was conducted in .E.D. of Aga Khan University Hospital (AKUH) Karachi from March 2020-September 2021. AKU\u0026rsquo;s ..E.D. is a 60 bedded emergency room with 17 dedicated pediatric beds. In our .E.D., we see around 15000 pediatric patients a year. AKUH receive patients from Sindh and neighboring provinces like Punjab, Baluchistan, and Khyber Pakhtunkhwa. All children (1 month to -16 years) with signs and symptoms suggestive of PMIS according to WHO preliminary definition criteria regardless of COVID-19 positive or negative. were included in the study. Predesigned questionnaire was used for data collection. Data were collected regarding patient demographics, presenting complaints, investigation performed, treatment offered and outcome \u0026nbsp; during the emergency room stay.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMicrosoft Excel Spreadsheet (2010) was used for data management \u0026amp; cleaning and then transported into SPSS-22 (IBM, IL, USA) for statistical analysis. The data were analyzed using descriptive statistics; results were reported as numbers with percentages for qualitative variables and expressed as mean \u0026plusmn; standard deviation or medians with ranges for continuous variables. The Mann-Whitney U test compared the in-hospital mortality with triage vitals, e.g. (SBP \u0026amp; DBP, H.R., R.R.), to see any significant differences between Alive and Expired. For finding the association between the groups (alive/expired), the Chi-square test or Fisher exact test was used for categorical data. Continuous outcomes (if the normality assumption is satisfied) were compared using a t-test. a After selecting confounding indicators of the study, we carried out the univariate analysis, taking mortality as a dependent variable and selecting significant variables in the univariate model. Independent variables with a p-value of \u0026lt;0.2 were used in a multiple binary logistic regression model. We developed multivariate models using the stepwise backward likelihood function. In the multivariate models, the p-value of less than or equal to 0.05 was considered significant.\u003c/p\u003e\n\u003cp\u003eThe areas under each receiver operating characteristic curves (AUC of ROC curve) were calculated to compare the overall discriminatory power of different laboratory markers in predicting in-hospital mortality. Values of AUC higher than 0.8 were considered as good, between 0.6-0.8 as acceptable or moderate, and lower than 0.6 as poor to determine the threshold value of different clinical markers in terms of different sensitivities and specificities. Our primary endpoint was the in-hospital mortality rate. Results were reported as ODD Radio (OR) with a 95 % confidence interval.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTotal of 56 patients were diagnosed with pediatric multisystem inflammatory syndrome. The mean age of the patients was 7.67\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8 (ranging from 1 to 16 years). All age groups (infants, children and adolescents) were equally affected. There was a male pre dominance in our study(85.7%). \u003cb\u003ePatient demographics are shown in\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive \u0026amp; Baseline Characteristics of Pediatric multi system inflammatory syndrome\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean \u0026plusmn; .D.S.D. (Range)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.67 (\u0026plusmn;\u0026thinsp;4.8) (1\u0026ndash;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight in Kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.46 (\u0026plusmn;\u0026thinsp;17.1) (3.5\u0026ndash;82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of Hospital Stay (In Days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.14 (\u0026plusmn;\u0026thinsp;6) (1\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge Groups\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePercentage (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eFrequency (f)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 Day to 1 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.40%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;5 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;16 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.30%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.70%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e.\u003cb\u003eR.E.R. Stay\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean \u0026plusmn; .D.S.D. (Range: Min-Max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.41\u0026thinsp;\u0026plusmn;\u0026thinsp;3.10 (1.5 to 16.5 Days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;4 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;=4 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital Stay\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean \u0026plusmn; .D.S.D. (Range: Min-Max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.14\u0026thinsp;\u0026plusmn;\u0026thinsp;5.97 (1to 30 Days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5 Days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;=5 Days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatus\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExpired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe main presenting complaints were related to respiratory 70%, neurological 57%, Gastrointestinal 54%, and skin manifestations 34%. Delayed capillary refill time (93%), low volume pulses (89%) and tachycardia(60%) were the most common clinical signs suggestive of shock state. Non purulent conjunctivitis (16.1%), and Strawberry tongue were seen (28.6%) cases. \u003cb\u003ePresenting complaints and examinations findings are shown in\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePresenting complain and examination findings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean \u0026plusmn; .D.S.D. (Range)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (f)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresenting Complain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(39)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastrointestinal Symptoms (G.I)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin Manifestations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurological Symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmergency Vitals\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean \u0026plusmn; .D.S.D. (Range: Min-Max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86.96 (\u0026plusmn;\u0026thinsp;15.4) (50\u0026ndash;110)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.11 (\u0026plusmn;\u0026thinsp;12.5) (30\u0026ndash;76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137.29 (\u0026plusmn;\u0026thinsp;28.3) (84\u0026ndash;221)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.16 (\u0026plusmn;\u0026thinsp;9.8) (20\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTachycardia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.70%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(34)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTemperature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.3 (\u0026plusmn;\u0026thinsp;2.2) (27\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.05 (\u0026plusmn;\u0026thinsp;3.2) (3\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCapillary Refill time (CRT)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2 sec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;=2 sec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePulses\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGeneral Physical Examination\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCervical lymph\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.70%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConjunctivitis_Non_purulent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrawberry tongue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin Manifestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.90%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePedal edema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eScreening for COVID-19 was done in all 56 patients; initially, PCR were sent, and if PCR negative, covid antibodies were sent. COVID PCR was positive in only 18% (10) patients whereas COVID antibodies were positive in 78.6% (44). Out of 12 patients who had negative COVID antibodies, 10(83.3%) patients were tested PCR positive, whereas only 2 (16.7%) patients had both antibody body and PCR negative. \u003cb\u003eD\u003c/b\u003eescriptive characteristics of Hematological, inflammatory biomarkers and biochemistry parameters. \u003cb\u003eShown in\u003c/b\u003e Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHematological, inflammatory and biochemical markers in patients with PMIS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBaseline and Demographics variables\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean \u0026plusmn; .D.S.D. (Range)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInflammatory Markers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135.37 (\u0026plusmn;\u0026thinsp;99.6) (0.37-383.59)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.09 (\u0026plusmn;\u0026thinsp;23.2) (2\u0026ndash;74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFerritin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2497.6 (\u0026plusmn;\u0026thinsp;3881.1) (76.4-17729)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFerritin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2497.6 (\u0026plusmn;\u0026thinsp;3881.1) (76.4-17729)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLDH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e945.22 (\u0026plusmn;\u0026thinsp;1652.4) (219-10176)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCardiac Marker\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrop_I_\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.06 (\u0026plusmn;\u0026thinsp;115.5) (0.01\u0026ndash;739)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePro_BNP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38194 (\u0026plusmn;\u0026thinsp;79957.9) (75-376052)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEjection Fraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (\u0026plusmn;\u0026thinsp;15) (6\u0026ndash;71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHematological Parameters\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.2 (\u0026plusmn;\u0026thinsp;1.7) (6.9\u0026ndash;13.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTLC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.12 (\u0026plusmn;\u0026thinsp;6.7) (1.6\u0026ndash;26.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutrophil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.11 (\u0026plusmn;\u0026thinsp;20.1) (10.7\u0026ndash;94.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymphocyte\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.73 (\u0026plusmn;\u0026thinsp;17.7) (3.3\u0026ndash;83.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelet counts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e217.02 (\u0026plusmn;\u0026thinsp;160.6) (15\u0026ndash;709)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBio chemistry Parameters\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.01 (\u0026plusmn;\u0026thinsp;41.6) (0.12\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137.11 (\u0026plusmn;\u0026thinsp;9.1) (125\u0026ndash;172)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.08 (\u0026plusmn;\u0026thinsp;1.4) (1.8\u0026ndash;9.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102.75 (\u0026plusmn;\u0026thinsp;8.6) (92\u0026ndash;139)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.94 (\u0026plusmn;\u0026thinsp;5.9) (5.1\u0026ndash;30.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003elactate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.65 (\u0026plusmn;\u0026thinsp;3.6) (0.7\u0026ndash;14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBun\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.56 (\u0026plusmn;\u0026thinsp;16.4) (5\u0026ndash;94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.81 (\u0026plusmn;\u0026thinsp;0.5) (0.3\u0026ndash;2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCoagulation profile\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.77 (\u0026plusmn;\u0026thinsp;22.9) (10.1\u0026ndash;170)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAPTT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.49 (\u0026plusmn;\u0026thinsp;30.3) (24.7\u0026ndash;170)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.83 (\u0026plusmn;\u0026thinsp;2.3) (0.9\u0026ndash;17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD DIMER\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.32 (\u0026plusmn;\u0026thinsp;11.8) (0.3\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAntibody\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon Reactive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(12) 21.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReactive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(44) 78.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePCR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(46) 82.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(10) 17.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBased on the multivariate binary regression model indicated that the risk for mortality was higher in patients with .E.D. Stay of more than 4 Hours (OR\u0026thinsp;=\u0026thinsp;5.4, 95% CI: 1.27 to 22.93), a total hospital stay of more than five days (OR\u0026thinsp;=\u0026thinsp;0.17, 95% CI: 0.02 to 0.64), hypotension at presentation (OR\u0026thinsp;=\u0026thinsp;4.25, 95% CI: 1.02 to 17.69), hemoglobin level\u0026thinsp;\u0026lt;\u0026thinsp;9 g/L (OR\u0026thinsp;=\u0026thinsp;5.68, 95% CI: 1.08\u0026ndash;29.8), Ferritin level of \u0026gt;\u0026thinsp;322(OR\u0026thinsp;=\u0026thinsp;23.5, 95% CI\u0026thinsp;=\u0026thinsp;2.5 to 61.3), and Lactate Dehydrogenase (LDH)\u0026thinsp;\u0026gt;\u0026thinsp;246 U/L (OR\u0026thinsp;=\u0026thinsp;20.5, 95% CI\u0026thinsp;=\u0026thinsp;3.85 to 53.6). \u003cb\u003e(Table\u0026nbsp;4)\u003c/b\u003e\u003c/p\u003e\n\u003cp\u003eTable:4 Univariate and multivariate binary regression for the prediction of mortality in\u0026nbsp;PMIS\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"641\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"47.97507788161994%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"26.4797507788162%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"25.54517133956386%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOR [95% CI]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOR [95% CI]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMale gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.6 [0.1 -3.53]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.572\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDialysis (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 [1.37 -35.68]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.019*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHypotension (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.25 [1.02 -17.69]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.047*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.25 [2.78 -59.15]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.027*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTachycardia (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.22 [1.19 -32.68]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.031*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e.I.G.I. Symptoms (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 [1.05 -76.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.045*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eETT (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.64 [3.26 -151.86]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFFP (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.4 [1.27 -22.93]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.028*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVitamin K (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.14 [1.72 -48.66]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.009*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNorepinephrine (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.27 [1.56 -43.81]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.013*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.91 [0.68 -12.73]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eED Stay \u0026gt;=4 Hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.4 [1.27 -22.93]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.022*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15.75 [1.25 -198.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.033*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHospital Stay \u0026gt;=5 Days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.19 [0.04 -0.83]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.028*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.17 [0.02 -1.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.088\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHemoglobin level (\u0026lt;=9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.68 [1.08 -29.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.04*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.27 [1.81 -28.49]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.043*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eActivated partial thromboplastin time (APTT) \u0026gt;=35 \u0026nbsp; \u0026nbsp; sec\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.3 [0.56 -9.54]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePlatelet level \u0026lt;150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.17 [0.72 -13.87]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFerritin level (\u0026gt;=322 ng/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14 [10.6 -56.33]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.017*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.5 [2.5 -61.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.011*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePro_BNP (\u0026gt;1000 pg/ml )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.82 [1.15 -83.91]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.037*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTroponin level (\u0026gt;0.006 ng/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.39 [0.37 -31.33]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.282\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eD-Dimer level (\u0026gt;0.5 \u0026mu;/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.49 [1.54 -18.66]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.032*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.75 [1.86 -40.53]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.046*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLDH level (\u0026gt;246 U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 [2.85 -56.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.045*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.5 [3.85 -53.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.024*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e.T.P.T. level (\u0026gt;12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.67 [1.59 -47.15]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.012*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eINR level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.2 [2.03 -61.89]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.006*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLactate level (\u0026gt;=4 mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.29 [0.29 -5.68]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.739\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAbbreviations: C.I, Confidence interval, OR, Odd ratios\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eUnivariate and multivariate logistic regression for the prediction of mortality\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e(International Normalized Ratio=INR, PT= prothrombin Time, ED= Emergency, LDH=Lactate dehydrogenase, BNP= B-type natriuretic peptide\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003c/br\u003e\n \u003cp\u003eThe ROC curves for predicting mortality are displayed in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The calculated AUC values were as follows: 0.831 (95%CI: 0.684\u0026ndash;0.978) for the LDH, 0.708 (95%CI: 0.508\u0026ndash;0.908) for the ferritin level, 0.627 (95%CI: 0.394\u0026ndash;0.859) for the D-Dimer, 0.815 (95%CI: 0.634\u0026ndash;0.996) for the APTT, 0.737 (95%CI: 0.489\u0026ndash;0.985) for the lactate Each model produced statistically significant AUCs with respectable and comparable values. The AUCs were compared, but no real differences were found. However, it might be argued that the LDH, ferritin, lactate, and D-Dimer provide the best discriminatory power.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this article, we report the data of 56 patients who came to Aga Khan University Hospital (AKUH). They were diagnosed with PMIS, fulfilling the inclusion criteria mentioned by RCPCH.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e While there is a plethora of studies done on PMIS, this is the first study that highlights the cases coming to the. ED. in a developing country like Pakistan. In our study, children with a median age of 7.67 years were diagnosed with PMIS with male gender dominance of 85%. 70% of patients presented with respiratory complaints followed by 57% neurological. In a study done on children in Latin America, it was 3 years and, in a study, done in France and Switzerland, it was ten years.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e There have been considerably more males diagnosed with MIS-C than women, and the same pattern was also found in our sample, hinting at some factor that puts this gender at a greater risk. \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, 19\u003c/sup\u003eAnother study in New York revealed that the majority of children diagnosed were aged between 6 and 12 years, 80% reported gastrointestinal symptoms, and 63% had cardiovascular symptoms associated with echocardiographic abnormalities and hypotension. Majority of children require intensive care treatment.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGastrointestinal complaints were common in the expired group in our patient sample however, the most common patient complaint in our sample was respiratory complaints followed by neurological complaints. This is contrasting with a study done in the .U.S. across 26 states where the gastrointestinal involvement was 92% while those with respiratory symptoms were 70% of the total sample and another systematic review on MIS-C in which ⅘ of the sample had diarrhea and abdominal pain which was described so severe that patients were presumed to have appendicitis. \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e As we know that SARS-COV2 spreads through its effects on angiotensin converting enzyme receptors (ACE receptors) that are present throughout our body but especially in the lungs, which is why its main effects is on the lungs. More common .G.I. effects might be because of transmission of virus through GIT or feco-oral transmission due to the ACE2 receptors in intestines and this also explains the spread of disease in children considering their lack in hand hygiene, but they generally acquire a milder or asymptomatic disease due to their immature immune system. \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e More evidence suggests that this condition presents a few weeks after COVID infection in children when it is cleared from the upper respiratory tract, hence .G.I. symptoms being more common. \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe covid screening was done in all patients; in most patients, positive serology was seen, while some also had a positive PCR. It is because the onset of this condition is after several weeks when the PCR is no longer positive and antibodies have been made. This is also consistent with most studies suggesting PMIS could be due to the antibodies made against the virus that might play a role in bringing the cytokine storm and result in a hyper inflammatory state.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e A more severe case has also been associated with antibody-dependent enhancement in which a type of antibody is made which cannot neutralize the virus ultimately promoting virus growth.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMost of the sample population presented with abnormal ECG, which is one of the diagnoses for myocarditis since sinus tachycardia is one of the most common findings in myocarditis.25 and multiple studies have shown COVID-19. PMIS is associated with myocarditis-like symptoms presenting with arrhythmias.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Similarly, in our results, sinus tachycardia was the main finding, along with ventricular tachycardia. Due to this, almost all the patients in our population had delayed capillary refill time and had cardiac resynchronization therapy for less than 2 seconds.\u003c/p\u003e \u003cp\u003eResearch has shown that inflammatory markers, especially the ones indicating cardiac injury, including ESR, ferritin, LDH, fibrinogen, and CRP levels, were higher in patients meeting the PMIS criteria resulting from the pathogenesis.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e In our study, increased stroponin, ferritin, INR, D-dimer, and Pro-BNP showed a higher mortality risk. Especially patients with LDH greater than were heavily associated with the expired group.\u003c/p\u003e \u003cp\u003eIn the current study, even though the number of patients who expired was not high after being admitted to the .ED. or the hospital, the expired group was associated with staying in the hospital for more than five days, increasing theirs by nine folds. This contrasts with studies with notably low expiry rates for patients with greater lengths of stay and admitted to the Intensive Care Unit.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOnly the data from inside AKUH was used for this paper which limited the sample size. The method of collection and analysis did not compare people with different geographical or social background. Furthermore, for diagnosis of COVID-19, only throat PCR was used, as other methods, like stool PCR, were not available at the facilities. This method can be used to detect SARS-COV-2 after it has been cleared from the upper respiratory tract as discussed above.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMajority of the children with PMIS were antibody positive against COVID-19.Respiratory and gastrointestinal symptoms were the most common presenting complaints and majority of the patients were in shock like condition. Hypotension, low Hemoglobin, raised LDH and.Ferriten along with increased length of ED stay were associated with increase risk for mortality.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll methods were carried out according to \u0026ldquo;deleration of helesenki.\u0026rdquo; Ethical approval was obtained from Ethical Review Committee, Aga Khan University, Karachi Pakistan. Consent was waived from Ethical Review Committee, Aga Khan University, Karachi Pakistan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: \u0026nbsp;Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author [email protected] on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e There are no competing interest \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No funding required\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSB \u0026amp; SA: Conceptualization, Supervision and Writing, revieing and editing.\u003c/p\u003e\n\u003cp\u003eAR- Methodology \u0026amp; Analysis\u003c/p\u003e\n\u003cp\u003eMT- Data Curation, Writing, revieing and editing.\u003c/p\u003e\n\u003cp\u003eIA- Writing, revieing and editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll author\u0026rsquo;s reviewed and approved final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Not applicable\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGudbjartsson DF, Helgason A, Jonsson H, et al. 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Clinical Characteristics of 5 COVID-19 Cases With Non-respiratory Symptoms as the First Manifestation in Children. Front Pediatr. 2020 May 12;8:258. doi: 10.3389/fped.2020.00258. PMID: 32574284; PMCID: PMC7235428\u003c/li\u003e\n \u003cli\u003eGrama A, Căinap SS, Mititelu A, Blag C, Simu C, Burac L, Simionescu B, Mărgescu C, Sur G, Sp\u0026acirc;rchez M, Bota M, Tănasă B, Pop TL. Multisystemic Inflammatory Syndrome in Children, A Disease with Too Many Faces: A Single-Center Experience. J Clin Med. 2022 Sep 6;11(18):5256. doi: 10.3390/jcm11185256. PMID: 36142902; PMCID: PMC9504807.\u003c/li\u003e\n \u003cli\u003eZhao Y, Yin L, Patel J, Tang L, Huang Y. The inflammatory markers of multisystem inflammatory syndrome in children (MIS-C) and adolescents associated with COVID-19: A meta-analysis. J Med Virol. 2021 Jul;93(7):4358-4369. doi: 10.1002/jmv.26951. Epub 2021 Apr 1. PMID: 33739452; PMCID: PMC8250955.\u003c/li\u003e\n \u003cli\u003eTahir F, Bin Arif T, Ahmed J, Malik F, Khalid M. Cardiac Manifestations of Coronavirus Disease 2019 (COVID-19): A Comprehensive Review. Cureus. 2020;12(5):e8021. Published 2020 May 8. doi:10.7759/cureus.8021.\u003c/li\u003e\n \u003cli\u003eMost ZM, Hendren N, Drazner MH, Perl TM. Striking Similarities of Multisystem Inflammatory Syndrome in Children and a Myocarditis-Like Syndrome in Adults: Overlapping Manifestations of COVID-19. Circulation. 2021;143(1):4-6. doi:10.1161/CIRCULATIONAHA.120.050166\u003c/li\u003e\n \u003cli\u003eWhittaker E, Bamford A, Kenny J, et al. Clinical Characteristics of 58 Children With a Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2. JAMA. 2020;324(3):259-269. doi:10.1001/jama.2020.10369\u003c/li\u003e\n \u003cli\u003eBustos B R, Jaramillo-Bustamante JC, Vasquez-Hoyos P, Cruces P, D\u0026iacute;az F. Pediatric Inflammatory Multisystem Syndrome Associated With SARS-CoV-2: A Case Series Quantitative Systematic Review. Pediatr Emerg Care. 2021;37(1):44-47. doi:10.1097/PEC.0000000000002306\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pediatric, inflammatory syndrome, COVID-19, Emergency ","lastPublishedDoi":"10.21203/rs.3.rs-2544129/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2544129/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePediatric multisystem inflammatory syndrome (PMIS) is a hyperinflammatory syndrome with multi organ involvement. In children, severe complications were reported with features similar to incomplete Kawasaki disease during later phases of COVID- 19 infection.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThis study aimed to determine the frequency, pattern of presentation, and significant laboratory parameters related to PMIS in children presenting to the emergency department during COVID \u0026minus;\u0026thinsp;19.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis was a prospective observational study. Children (1 month \u0026minus;\u0026thinsp;16 years) with symptoms suggestive of PMIS were included. A predesigned questionnaire was used to collect data on demographics, presenting complaints, performing investigations, offering treatment, and the outcome during the emergency stay. Besides using descriptive statistics, the Mann-Whitney U test compared the in-hospital mortality with triage vitals to see any significant differences between Alive and Expired. The Chi-square test or Fisher exact test was used for categorical data to see the association.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003e56 patients, majority male (85.7%), were diagnosed with the pediatric multisystem inflammatory syndrome with a mean age of 7.67\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8 (ranging from 1 to 16 years). COVID PCR was positive in only 18% (10) patients, whereas COVID antibodies were positive in 78.6% (44). The main presenting complaints were related to respiratory 70% followed by neurological 57% and Gastrointestinal 54% with the common clinical sign of delayed capillary refill time (93%) and low volume pulses (89%). Out of 12 patients with negative COVID antibodies, 10(83.3%) patients tested PCR positive, whereas only 2 (16.7%) patients had both antibody body and PCR negative. Based on the multivariate binary regression model indicated that the risk for mortality was higher in patients with ED Stay of more than 4 Hours (OR\u0026thinsp;=\u0026thinsp;5.4), a total hospital stays of more than five days (OR\u0026thinsp;=\u0026thinsp;0.17, 95% CI: 0.02 to 0.64).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMost children with PMIS were found to have positive antibodies against COVID-19. An increased ED stay was associated with poor outcomes.\u003c/p\u003e","manuscriptTitle":"Assessing pattern of the pediatric multisystem inflammatory syndrome (PMIS) in children during COVID-19 infection: Experience from the emergency department of a LMICs tertiary care hospital. 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