Quantitative SARS-CoV-2 Serology in Children With Multisystem Inflammatory Syndrome (MIS-C)

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We aimed to measure severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serological responses in children hospitalized with multisystem inflammatory syndrome in children (MIS-C) compared with those with coronavirus disease 2019 (COVID-19), those with Kawasaki disease (KD), and hospitalized pediatric controls.


From March 17, 2020, to May 26, 2020, we prospectively identified hospitalized children with MIS-C (n = 10), symptomatic COVID-19 (n = 10), and KD (n = 5) and hospitalized controls (n = 4) at Children’s Healthcare of Atlanta. With institutional review board approval, we obtained prospective and residual blood samples from these children and measured SARS-CoV-2 spike receptor-binding domain (RBD) immunoglobulin M and immunoglobulin G (IgG), full-length spike IgG, and nucleocapsid protein antibodies using quantitative enzyme-linked immunosorbent assays and SARS-CoV-2 neutralizing antibodies using live-virus focus-reduction neutralization assays. We statistically compared the log-transformed antibody titers among groups and performed linear regression analyses.


All children with MIS-C had high titers of SARS-CoV-2 RBD IgG antibodies, which correlated with full-length spike IgG antibodies (R2 = 0.956; P < .001), nucleocapsid protein antibodies (R2 = 0.846; P < .001), and neutralizing antibodies (R2 = 0.667; P < .001). Children with MIS-C had significantly higher SARS-CoV-2 RBD IgG antibody titers (geometric mean titer 6800; 95% confidence interval 3495–13 231) than children with COVID-19 (geometric mean titer 626; 95% confidence interval 251–1563; P < .001), children with KD (geometric mean titer 124; 95% confidence interval 91–170; P < .001), and hospitalized controls (geometric mean titer 85; P < .001). All children with MIS-C also had detectable RBD immunoglobulin M antibodies, indicating recent SARS-CoV-2 infection. RBD IgG titers correlated with the erythrocyte sedimentation rate (R2 = 0.512; P < .046) and with hospital (R2 = 0.548; P = .014) and ICU lengths of stay (R2 = 0.590; P = .010).


Quantitative SARS-CoV-2 serology may have a role in establishing the diagnosis of MIS-C, distinguishing it from similar clinical entities, and stratifying risk for adverse outcomes.

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  1. SciScore for 10.1101/2020.07.10.20150755: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementConsent: With IRB approval, samples were collected prospectively when parental consent was possible and residual samples were obtained if consent was not possible.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.
    Cell Line Authenticationnot detected.

    Table 2: Resources

    Definition of Cohorts: SARS-CoV-2 ELISAs: We previously described the cloning, expression, and purification of a recombinant form of the spike (S) RBD from SARS-CoV-2.12 We measured anti-RBD antibodies by enzyme- linked immunosorbent assays (ELISAs) in duplicate as described.
    suggested: None
    12 Secondary antibodies used for development were anti-hu-IgG-HRP and anti-hu-IgM-HRP (Jackson Immuno Research).
    suggested: None
    suggested: None
    Experimental Models: Cell Lines
    The antibody-virus mixture was aliquoted onto a monolayer of VeroE6 cells and incubated at 37°C for 1 hour.
    suggested: JCRB Cat# JCRB1819, RRID:CVCL_YQ49)
    Software and Algorithms
    Statistical Methods: Statistical comparisons were made using GraphPad Prism version 8.0.
    GraphPad Prism
    suggested: (GraphPad Prism, RRID:SCR_002798)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Our study has several limitations including a small sample size. Results should be corroborated in a larger cohort representing varying clinical phenotypes. Second, detection of SARS-CoV-2 binding and neutralizing antibodies in children with MIS-C demonstrates association, but not necessarily causation. Also, as the seroprevalence of SARS-CoV-2 antibodies increases, the clinical significance of these antibodies may eventually become obscured. Several patients with MIS-C had specimens drawn after administration of IVIG, which conceivably could have affected SARS-CoV-2 antibody titers. However, 4 of 5 patients with KD also received IVIG prior to specimen collection, with negligible effects on RBD titers. A recent study demonstrated various IVIG products lack cross-reactivity with the SARS-CoV-2 RBD.15 In conclusion, we found that all children with MIS-C had high titers of SARS-CoV-2 RBD IgG antibodies which correlated with neutralization. RBD IgG antibodies also correlated with metrics of systemic inflammation and with clinical outcomes. Thus, measuring quantitative SARS-CoV-2 RBD antibody titers may have a role in establishing the diagnosis of MIS-C, distinguishing it from other similar clinical entities, and stratifying risk for adverse outcomes.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a protocol registration statement.

    About SciScore

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