Use of tocilizumab in multisystem inflammatory syndrome in children associated with severe acute respiratory syndrome coronavirus 2.

To the Editor:

Kaushik et al provide a comprehensive overview of characteristics of the multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). All 33 children had evidence of SARS-CoV-2 infection in the form of positive reverse-transcription polymerase chain reaction and/or positive antibody test. Similar to routine (non–SARS-CoV-2 related) Kawasaki disease, the most common treatment modality employed was intravenous immunoglobulin. Nearly one-half of the cohort received glucocorticoids; anti-interleukin (IL)-1 and anti-IL-6 agents were used in 12 and 4 patients, respectively. Tocilizumab was used in children with prominent coronary arteries on echocardiography but not in children with coronary artery ectasia. Large studies on MIS-C , mention the successful use of tocilizumab in controlling inflammation; however, data on the outcome of coronary artery abnormalities are lacking. Putative worsening of coronary artery aneurysms is a significant concern in children with Kawasaki disease treated with tocilizumab. Tocilizumab has been used to mitigate the cytokine storm associated with SARS-CoV-2, both in children as well as adults , ; however, levels of IL-6 seem to be lower in MIS-C as compared with severe SARS-CoV-2 infection in adults.

If the authors could provide additional follow-up data of coronary artery abnormalities in patients in whom tocilizumab was used, this could serve as baseline evidence for the efficacy of anti-IL-6 agents in MIS-C concerning coronary artery outcomes. We envisage tocilizumab to be used more often in children with intravenous immunoglobulin–refractory MIS-C in India, as anti-IL-1 agents are not available in commercial markets.