RESUMO Objetivo: Abordar a prática atual de desmame da ventilação mecânica invasiva de pacientes em unidades de terapia intensiva pediátrica, com foco no uso de protocolos, critérios, parâmetros e indicações padronizados para suporte respiratório não invasivo após a extubação. Métodos: Realizou-se uma busca eletrônica de novembro de 2021 a maio de 2022 em unidades de terapia intensiva pediátrica ibero-americanas. Participaram médicos e terapeutas respiratórios, com um único representante de cada unidade de terapia intensiva pediátrica incluída. Não houve intervenções. Resultados: A taxa de resposta foi de 48,9% (138/282), representando 10 países ibero-americanos. Em apenas 34,1% (47/138) das unidades de terapia intensiva pediátrica havia protocolos escritos de desmame de ventilação mecânica invasiva, e seu uso estava associado à presença de terapeutas respiratórios (RC 3,85; IC95% 1,79 - 8,33; p = 0,0008). O método mais comum de desmame envolveu uma redução gradual do suporte ventilatório mais um teste de respiração espontânea (47,1%). A duração média da tentativa de respiração espontânea foi de 60 a 120 minutos em 64,8% das respostas. A presença de um terapeuta respiratório na unidade de terapia intensiva pediátrica foi a única variável associada ao uso de um teste de respiração espontânea como o principal método de desmame da ventilação mecânica invasiva (RC 5,1; IC95% 2,1 - 12,5). Os protocolos de suporte respiratório não invasivo não foram usados com frequência após a extubação (40,4%). Quase metade dos respondentes (43,5%) relatou preferência pelo uso de pressão positiva de dois níveis nas vias aéreas como modo de ventilação não invasiva após a extubação. Conclusão: Uma grande proporção de unidades de terapia intensiva pediátrica ibero-americanas não possui protocolos de desmame. Nosso estudo destaca uma variabilidade substancial nas práticas de prontidão para extubação, ressaltando a necessidade de padronização desse processo. No entanto, a presença de um terapeuta respiratório foi associada a uma maior adesão às diretrizes. Objetivo critérios Métodos Realizouse Realizou se 202 iberoamericanas. iberoamericanas ibero americanas. americanas incluída intervenções Resultados 489 48 9 48,9 138/282, 138282 138/282 , 138 282 (138/282) 1 iberoamericanos. iberoamericanos americanos. americanos ibero-americanos 341 34 34,1 47/138 47138 47 (47/138 RC 3,85 385 3 85 IC95 IC 179 79 1,7 8,33 833 8 33 0,0008. 00008 0,0008 . 0 0008 0,0008) 47,1%. 471 47,1% (47,1%) 6 12 648 64 64,8 respostas 5,1 51 5 21 2 2, 12,5. 125 12,5 12,5) 40,4%. 404 40,4% 40 4 (40,4%) 43,5% 435 43 (43,5% Conclusão processo entanto diretrizes 20 48, 13828 138/28 13 28 (138/282 34, 47/13 4713 (47/13 3,8 38 IC9 17 7 1, 8,3 83 0000 0,000 000 47,1 (47,1% 64, 5, 12, 40,4 (40,4% 43,5 (43,5 1382 138/2 (138/28 47/1 (47/1 3, 8, 0,00 00 47, (47,1 40, (40,4 43, (43, 138/ (138/2 47/ (47/ 0,0 (47, (40, (43 (138/ (47 0, (40 (4 (138 ( (13 (1

ABSTRACT Objective: To address the current practice of liberating patients from invasive mechanical ventilation in pediatric intensive care units, with a focus on the use of standardized protocols, criteria, parameters, and indications for noninvasive respiratory support postextubation. Methods: Electronic research was carried out from November 2021 to May 2022 in Ibero-American pediatric intensive care units. Physicians and respiratory therapists participated, with a single representative for each pediatric intensive care unit included. There were no interventions. Results: The response rate was 48.9% (138/282), representing 10 Ibero-American countries. Written invasive mechanical ventilation liberation protocols were available in only 34.1% (47/138) of the pediatric intensive care units, and their use was associated with the presence of respiratory therapists (OR 3.85; 95%CI 1.79 - 8.33; p = 0.0008). The most common method of liberation involved a gradual reduction in ventilatory support plus a spontaneous breathing trial (47.1%). The mean spontaneous breathing trial duration was 60 - 120 minutes in 64.8% of the responses. The presence of a respiratory therapist in the pediatric intensive care unit was the only variable associated with the use of a spontaneous breathing trial as the primary method of liberation from invasive mechanical ventilation (OR 5.1; 95%CI 2.1 - 12.5). Noninvasive respiratory support protocols were not frequently used postextubation (40.4%). Nearly half of the respondents (43.5%) reported a preference for using bilevel positive airway pressure as the mode of noninvasive ventilation postextubation. Conclusion: A high proportion of Ibero-American pediatric intensive care units lack liberation protocols. Our study highlights substantial variability in extubation readiness practices, underscoring the need for standardization in this process. However, the presence of a respiratory therapist was associated with increased adherence to guidelines. Objective criteria parameters Methods 202 IberoAmerican Ibero American participated included interventions Results 489 48 9 48.9 138/282, 138282 138/282 , 138 282 (138/282) 1 countries 341 34 34.1 47/138 47138 47 (47/138 OR 3.85 385 3 85 95CI CI 95 179 79 1.7 8.33 833 8 33 0.0008. 00008 0.0008 . 0 0008 0.0008) 47.1%. 471 47.1% (47.1%) 6 12 648 64 64.8 responses 5.1 51 5 21 2 2. 12.5. 125 12.5 12.5) 40.4%. 404 40.4% 40 4 (40.4%) 43.5% 435 43 (43.5% Conclusion practices process However guidelines 20 48. 13828 138/28 13 28 (138/282 34. 47/13 4713 (47/13 3.8 38 17 7 1. 8.3 83 0000 0.000 000 47.1 (47.1% 64. 5. 12. 40.4 (40.4% 43.5 (43.5 1382 138/2 (138/28 47/1 (47/1 3. 8. 0.00 00 47. (47.1 40. (40.4 43. (43. 138/ (138/2 47/ (47/ 0.0 (47. (40. (43 (138/ (47 0. (40 (4 (138 ( (13 (1

RESUMEN El objetivo del presente estudio fue describir las características de los pacientes pediátricos (entre 28 días y 14 años) hospitalizados con COVID-19 durante la tercera ola (variante ómicron) en el Hospital Nacional Edgardo Rebagliati Martins (HNERM) (Lima, Perú). En esta cohorte retrospectiva, se revisaron las historias clínicas de 122 pacientes pediátricos que fueron atendidos en el HNERM entre enero e inicios de abril del 2022 (55% varones, mediana de edad de 5 años), 77,9% durante el primer mes, y la mitad presentaron alguna comorbilidad. Se hospitalizaron principalmente por dificultad respiratoria, comorbilidad descompensada y deshidratación. El 6,6% ingresaron a cuidados intensivos, 4,9% a ventilación mecánica invasiva, 5,7% requirieron algún vasoactivo y 1,6% fallecieron. Los fármacos más usados fueron antibióticos (43,4%) y corticoides (27,1%). En conclusión, se encontró un incremento rápido de hospitalizaciones en comparación con las olas anteriores, la mayoría con evolución favorable, y con un amplio uso empírico de antibióticos.

ABSTRACT This study aimed to describe the characteristics of pediatric patients (28 days to 14 years of age) hospitalized with COVID-19 during the third wave of the pandemic (omicron variant) at the Hospital Nacional Edgardo Rebagliati Martins (HNERM) (Lima, Peru). In this retrospective cohort, we reviewed the medical records of 122 pediatric patients who attended HNERM between January and early April 2022 (55% male, median age: 5 years); 77.9% attended HNERM during the first month, and half of them had some comorbidity. Participants were hospitalized mainly for respiratory distress, decompensated comorbidity, and dehydration. Of the participants, 6.6% were admitted to intensive care, 4.9% to invasive mechanical ventilation, 5.7% required some vasoactive agent and 1.6% died. The most commonly used drugs were antibiotics (43.4%) and corticosteroids (27.1%). In conclusion, hospitalizations rapidly increased during the third wave, when compared to previous waves, most of them with favorable progression and with a wide empirical use of antibiotics.

ABSTRACT This study aimed to describe the characteristics of pediatric patients (28 days to 14 years of age) hospitalized with COVID-19 during the third wave of the pandemic (omicron variant) at the Hospital Nacional Edgardo Rebagliati Martins (HNERM) (Lima, Peru). In this retrospective cohort, we reviewed the medical records of 122 pediatric patients who attended HNERM between January and early April 2022 (55% male, median age: 5 years); 77.9% attended HNERM during the first month, and half of them had some comorbidity. Participants were hospitalized mainly for respiratory distress, decompensated comorbidity, and dehydration. Of the participants, 6.6% were admitted to intensive care, 4.9% to invasive mechanical ventilation, 5.7% required some vasoactive agent and 1.6% died. The most commonly used drugs were antibiotics (43.4%) and corticosteroids (27.1%). In conclusion, hospitalizations rapidly increased during the third wave, when compared to previous waves, most of them with favorable progression and with a wide empirical use of antibiotics.

RESUMEN El objetivo del presente estudio fue describir las características de los pacientes pediátricos (entre 28 días y 14 años) hospitalizados con COVID-19 durante la tercera ola (variante ómicron) en el Hospital Nacional Edgardo Rebagliati Martins (HNERM) (Lima, Perú). En esta cohorte retrospectiva, se revisaron las historias clínicas de 122 pacientes pediátricos que fueron atendidos en el HNERM entre enero e inicios de abril del 2022 (55% varones, mediana de edad de 5 años), 77,9% durante el primer mes, y la mitad presentaron alguna comorbilidad. Se hospitalizaron principalmente por dificultad respiratoria, comorbilidad descompensada y deshidratación. El 6,6% ingresaron a cuidados intensivos, 4,9% a ventilación mecánica invasiva, 5,7% requirieron algún vasoactivo y 1,6% fallecieron. Los fármacos más usados fueron antibióticos (43,4%) y corticoides (27,1%). En conclusión, se encontró un incremento rápido de hospitalizaciones en comparación con las olas anteriores, la mayoría con evolución favorable, y con un amplio uso empírico de antibióticos.

Resumen: El síndrome inflamatorio multisistémico pediátrico asociado a COVID-19 (SIM-C) es una entidad poco frecuente y heterogénea, potencialmente fatal. Existen pocos reportes de casos de esta enfer medad y de sus fenotipos en Latinoamérica. Objetivo: Describir las características de los fenotipos clínicos en pacientes hospitalizados en Lima, Perú, con diagnóstico de SIM-C. Pacientes y Méto do: Estudio retrospectivo de pacientes < 14 años con diagnóstico de SIM-C en el Hospital Nacional Edgardo Rebagliati Martins, Lima, Perú, abril 2020 - agosto 2021. Se registraron variables clínico-demográficas y microbiológicas. Según éstos, se clasificó a los pacientes con SIM-C en el fenotipo shock, enfermedad de Kawasaki (EK) sin shock, y el fenotipo fiebre e inflamación, analizando sus re sultados clínicos. Resultados: Se incluyeron 58 pacientes, 32 (55,2%) presentaron el fenotipo shock, 15 (25,8%) el fenotipo EK sin shock, y 11 (19%) el fenotipo fiebre e inflamación. Del fenotipo shock, 17 presentaron EK. La edad media fue de 7 ± 3,5 años y el 67,2% eran varones. Las manifestaciones gastrointestinales y mucocutáneas predominaron en todos los fenotipos. La mortalidad fue de 3,5%. La frecuencia de aneurismas coronarios fue del 10,2%. La mayoría de los pacientes recibió trata miento inmunomodulador y antiplaquetario. Los pacientes con fenotipo shock presentaron mayor disfunción hematológica, inflamatoria y cardiaca, con mayor frecuencia de insuficiencia respiratoria y ventilación mecánica invasiva. Conclusiones: En nuestra serie de casos, los pacientes con fenotipo shock fueron los más frecuentes y presentaron peores desenlaces clínicos. Se necesita una vigilancia activa de los fenotipos clínicos para un diagnóstico y manejo precoz con el fin de mejorar el pronós tico en estos pacientes.

Abstract: The multisystem inflammatory syndrome in children associated with COVID-19 (MIS-C) is infrequent but potentially lethal. There are few reports of this disease and its phenotypes in Latin America. Objective: To describe the characteristics of the clinical phenotypes of MIS-C in hospitalized patients in Lima, Peru. Patients and Method: A descriptive and retrospective study in patients under 14 years old with a diagnosis of MIS-C at the Hospital Nacional Edgardo Rebagliati Martins (Lima, Perú), from April 2020 to August 2021. Clinical-demographic and microbiological variables were recorded. According to these, patients with MIS-C were classified into the shock phenotype, Kawasaki disease (KD) without shock, and the fever and inflammation phenotype, analyzing their clinical outcomes. Results: 58 patients were analyzed. 32 (55.2%) presented the shock phenotype, 15 (25.8%) Kawasaki disease (KD) phenotype without shock, and 11 (19%) fever and inflammation phenotype. In the shock phenotype, 17 had KD. The mean age was 7 ± 3.5 years and 67.2% were males. Gastrointestinal and mucocutaneous manifestations predominated in all phenotypes. The mortality was 3.5%. The frequency of coronary aneurysms was 10.2%. Most patients received immunomodulatory and antiplatelet treatment. Patients with shock phenotype showed greater involvement in inflammatory markers, hematological dysfunction, and myocardial injury, with a higher frequency of respiratory failure and invasive mechanical ventilation. Conclusions: In our case series, patients with shock phenotype were the most frequent and had worse clinical outcomes. Active surveillance of clinical phenotypes is needed to make an early diagnosis and management to improve the prognosis in these patients.

RESUMO A síndrome da encefalopatia posterior reversível é uma rara síndrome clínica e radiológica caracterizada por edema vasogênico da matéria branca dos lobos occipital e parietal, que geralmente são simétricos, resultante de uma manifestação secundária de disfunção aguda do sistema cerebrovascular posterior. Descrevemos um caso de síndrome de encefalopatia posterior reversível secundária à infecção por SARS-CoV-2 em um menino de 9 anos de idade que desenvolveu insuficiência respiratória hipoxêmica aguda e necessitou de ventilação mecânica assistida. A criança desenvolveu síndrome inflamatória multissistêmica e foi monitorada na unidade de terapia intensiva pediátrica, tendo-lhe sido fornecidos ventilação mecânica e agentes vasoativos para suporte hemodinâmico. Além disso, desenvolveu manifestações clínicas pulmonares e extrapulmonares juntamente de manifestações neuropsiquiátricas que necessitavam de seguimento cuidadoso, tendo sido verificadas por ressonância magnética cerebral para intervenção oportuna. Atualmente, há poucos relatos de crianças com síndrome da encefalopatia posterior reversível associada à síndrome inflamatória multissistêmica.

ABSTRACT Posterior reversible encephalopathy syndrome is a rare clinical and radiological syndrome characterized by vasogenic edema of the white matter of the occipital and parietal lobes, which are usually symmetrical, resulting from a secondary manifestation of acute dysfunction of the posterior cerebrovascular system. We describe a case of posterior reversible encephalopathy syndrome secondary to SARS-CoV-2 infection in a 9-year-old boy who developed acute hypoxemic respiratory failure and required assisted mechanical ventilation. The child developed multisystem inflammatory syndrome, and he was monitored in the pediatric intensive care unit and was provided mechanical ventilation and vasoactive agents for hemodynamic support. Additionally, he developed pulmonary and extrapulmonary clinical manifestations along with neuropsychiatric manifestations that required close follow-up and were verified using brain magnetic resonance imaging for timely intervention. Currently, there are few reports of children with posterior reversible encephalopathy syndrome associated with multisystem inflammatory syndrome.

Resumen El cultivo de tomate genera grandes ganancias para México; sin embargo, la distribución del fruto enfrenta limitaciones debido a pérdidas postcosecha causadas por su rápido deterioro. La reducción en la firmeza del fruto se debe en parte a la degradación de la pectina localizada en la pared celular primaria. Varios frutos como fresa (Fragaria × ananassa), tomate (Solanum lycopersicum L.) y mango (Mangifera indica L.) muestran incremento en la expresión de genes que codifican para la enzima ramnogalacturonano liasa (RGL) durante la maduración. En tomate RGL es codificada por una familia de 13 multigenes, de los cuales tres están activos en fruto. Ramnogalacturonano I (RG-I) es un polisacárido que forma parte de las pectinas de la pared celular y que es degradado por la enzima RGL. En este sentido, el estudio de los cambios en expresión de genes que codifican para RGL durante el desarrollo y maduración del fruto de tomate ayudará a dilucidar la función fisiológica de esta familia de genes. El objetivo del presente estudio fue evaluar el perfil de expresión de los genes Solyc04g076630, Solyc04g076660 y Solyc11g011300 y la producción de etileno durante el desarrollo y maduración del fruto de tomate. El gen Solyc11g011300 mostró un incremento en actividad que correlacionó con el aumento en la producción de etileno del fruto, lo cual sugiere que este gen cumple una función en la pérdida de firmeza del fruto durante maduración. Los altos niveles de expression de los genes Solyc04g076630 y Solyc04g076660 registrados durante el desarrollo del fruto sugieren su participación en la re-ingeniería del polímero RG-I durante las etapas iniciales de desarrollo del fruto.

Summary Tomato cultivation generates great profits for Mexico; however, the distribution of the fruit faces limitations due to the postharvest losses caused by its rapid deterioration. The reduction in fruit firmness is due in part to the degradation of pectin located in the primary cell wall. Several fruits such as strawberry (Fragaria × ananassa), tomato (Solanum lycopersicum L.) and mango (Mangifera indica L.) show an increase in the expression of genes that code for the enzyme rhamnogalacturonan lyase (RGL) during ripening. In tomato RGL is encoded by a family of 13 multigenes, of which three are active in the fruit Rhamnogalacturonan l (RG-l) is a polysaccharide that is part of the pectins of the cell wall and is degraded by the RGL enzyme. Thus, the study of changes of RGL in the expression of genes that code for RGL during the development and ripening of tomato fruit will help to elucidate the physiological function of this family of genes. The objective of the present study was to assess the expression profile of genes Solyc04g076630, Solyc04g076660 and Solyc11g011300 and the ethylene production during the development and ripening of the tomato fruit. The Solyc11g011300 gene showed an increase in activity that correlated with the increase in ethylene production in fruits, suggesting that this gene plays a role in the loss of firmness of the fruit during ripening. The high levels of expression of genes Solyc04g076630 and Solyc04g076660 recorded during fruit development suggest their participation in the re-engineering of the RG-I polymer during the initial stages of fruit development.

Introduction The COVID-19 pandemic generated many controversies in the management of critically ill pediatric patients. The main ones were about ventilatory support, phenotypic differences between adults and children, and acute and subacute clinical forms. For this reason, the Respiratory Committee (RC) of the Latin American Society of Pediatric Intensive Care (SLACIP) generated a document to summarize the recommendations with the best evidence. The objective of these recommendations is to provide an update on issues related to pediatric COVID-19. Methods and Materials The Respiratory Committee created a group composed of 19 pediatric kinesiologists/physiotherapists and intensivists from 8 Latin American countries and defined on 3/27/20 the 15 most relevant topics, assigning 3 referents and 2 reviewers for each. The manuscripts went through 4 stages until their final version. The complete document was freely distributed on 22/05/20 and updated twice (07/08/20 and 02/09/21). For the current version there were 3 special collaborators. Result The material consists of a complete 94-page document and an executive summary. The topics included are case definition, epidemiology, clinical classification, subacute inflammatory syndrome, personal protective equipment, aerosolization situations (intubation, extubation, suctioning, sampling, filter replacement, cardiopulmonary resuscitation, early mobilization), high flow cannula support, invasive, non-invasive and high frequency mechanical ventilation, pharmacological treatment, laboratory and imaging. Conclusion The purpose of this document is to serve as a guide for nurses, kinesiologists/physiotherapists and physicians in the management of critically ill pediatric patients with COVID-19.

Introducción La pandemia por COVID-19 generó muchas controversias en el manejo de los pacientes pediátricos críticos. Las principales fueron sobre el soporte ventilatorio, las diferencias fenotípicas entre adultos y niños y las formas clínicas aguda y subaguda.Por esa razón el Comité Respiratorio (CR) de la Sociedad Latinoamericana de Cuidados Intensivos Pediátricos (SLACIP) generó un documento para resumir las recomendaciones con mayor evidencia. El objetivo de estas recomendaciones es brindar una actualización de temas relacionados a COVID-19 pediátrico.Métodos y Materiales El Comité Respiratorio creó un grupo compuesto por 19 kinesiólogos/fisioterapeutas y médicos intensivistas pediátricos de 8 países de Latinoamérica y definió el 27/03/20 los 15 temas más relevantes, asignando 3 referentes y 2 revisores por cada uno. Los manuscritos pasaron por 4 etapas hasta su versión final. El documento completo se distribuyó libremente el 22/05/20, actualizándose en dos oportunidades (07/08/20 y el 02/09/21). Para la versión actual se contó con 3 colaboradores especiales.Resultado El material se compone de un documento completo de 94 páginas y un resumen ejecutivo. Los temas incluidos son definición de caso, epidemiología, clasificación clínica, síndrome inflamatorio subagudo, equipos de protección personal, situaciones de aerosolización (intubación, extubación, aspiración, toma de muestras, recambio de filtros, reanimación cardiopulmonar, movilización temprana), soporte con cánula de alto flujo, ventilación mecánica invasiva, no invasiva y de alta frecuencia, tratamiento farmacológico, laboratorio e imágenes.Conclusión La elaboración de este documento ha tenido como fin servir de guía para enfermeros, kinesiólogos/fisioterapeutas y médicos en el manejo de pacientes pediátricos en estado crítico por COVID-19.

Acanthamoeba spp. and Balamuthia mandrillaris are causative agents of granulomatous amebic encephalitis (GAE), while Naegleria fowleri causes primary amebic meningoencephalitis (PAM). PAM is an acute infection lasting a few days, whereas GAE is a chronic or subacute infection that can last up to several months. In the present case we report a 10-year-old girl with amebic encephalitis symptomatology, evolution, medical-surgical intervention, specific therapy, and patient outcome. Cerebral involvement continues to have high mortality in pediatric patients, despite guided therapy through multimodal monitoring in pediatric intensive care, however noninvasive methods during cerebral evaluation play an important role in optimizing cerebral hemodynamics at the patient's bedside. We conclude that this case demonstrates the usefulness of multimodal monitoring, where we used intraparenchymal ICP sensor, conventional Transcranial Doppler, NIRS, color coded transcranial doppler, optic nerve sheath measurement, DVNO/DTO ratio, pupillometry, and EEG that helped to make appropriate decisions during the clinical evolution of our patient, which would help us to make an early diagnosis and avoid delays in interventions.

Acanthamoeba spp. y Balamuthia mandrillaris son agentes causantes de encefalitis amebiana granulomatosa (GAE), mientras que Naegleria fowleri causa meningoencefalitis amebiana primaria (PAM). La PAM es una infección aguda que dura unos pocos días, mientras que la GAE es una infección crónica o subaguda que puede durar hasta varios meses. En el presente caso reportamos a una niña de 10 años con sintomatología encefalitis amebiana, evolución, intervención médico-quirúrgicas, terapia específica y desenlace de la paciente. La afectación cerebral sigue teniendo alta mortalidad en los pacientes pediátricos, a pesar de la terapéutica guiada a través del monitoreo multimodal en cuidados intensivos pediátricos, sin embargo, los métodos no invasivos durante la evaluación cerebral, tiene un papel importante para optimizar la hemodinamia cerebral a la cama del paciente. Concluimos que este caso demuestra la utilidad del monitoreo multimodal, en donde utilizamos sensor PIC intraparenquimal, Doppler transcraneal convencional, Dúplex transcraneal codificado en color, NIRS, medición DVNO, ratio DVNO/DTO, pupilometría, y EEG que ayudó a tomar decisiones adecuadas durante la evolución clínica de nuestro paciente, que nos ayudaría hacer un diagnóstico precoz y evitar demoras en las intervenciones.

We report the case of an 11-year-old male adolescent, with symptoms of MISC-PIMS, negative RT-PCR and negative serology for COVID-19, family contact RT-PCR positive for COVID-19, treated in a referral hospital center, receiving treatment standardized for MIS-C, without response to initial therapy, despite receiving the same scheme on 3 occasions, classified as refractory, for which an expanded study was decided for other entities; finding hemophagocytic lymphohistiocytosis associated with systemic lupus erythematosus, an entity that often share similar inflammatory markers with the MISC, even usually confused with rheumatological, hematological and neoplastic entities, therefore the importance of reporting the case to identify this group refractory to treatment and identify another disease with expanded study, since it could be harmful or even fatal if a definitive diagnosis is not obtained.

Reportamos el caso de un adolescente varón de 11 años, con clínica de MISC-PIMS, RT-PCR negativa y serología negativa para COVID-19, contacto familiar RT-PCR positiva para COVID-19, atendido en un centro hospitalario referencial, recibiendo tratamiento estandarizado para MIS-C, sin respuesta a la terapéutica inicial, a pesar de recibir en 3 oportunidades el mismo esquema, catalogado como refractario, por lo que se decide estudio ampliado para otras entidades; encontrándose Linfohistiocitosis hemofagocítica asociada a Lupus eritematoso sistémico, entidad que muchas veces comparten marcadores inflamatorios similares con el MISC, inclusive usualmente confundida con entidades reumatológicas, hematológicas y neoplásicas, por eso la importancia de reportar el caso para identificar este grupo refractario al tratamiento e identificar otra enfermedad con estudio ampliado, ya que podría ser perjudicial hasta inclusive mortal si no se obtiene un diagnostico definitivo.