ABSTRACT
TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: An acute respiratory syndrome associated to the novel coronavirus SARS-CoV-2 has affected the entire world. Pediatric patients can rarely present with a severe complication identified as multisystem inflammatory syndrome in children (MIS-C).(1) After its recognition by the CDC and media reports of young adults with the same syndrome, a series of cases in adults (MIS-A) was published in late 2020.(2) CASE PRESENTATION: A 25-year-old Hispanic male who tested positive for SARS-CoV-2 by RT-PCR six weeks prior presented to the emergency department with one week of sore throat, fever, non-bloody diarrhea, conjunctivitis, and mild confusion. On examination, the patient was febrile, had tender submandibular lymph nodes and redness on the oropharynx. Initial laboratory results showed systemic inflammation. COVID-19 RT-PCR test was negative, coronavirus IgG was positive, and chest radiograph was normal. On the third day, the patient's clinical status deteriorated despite antibiotic use with hypotension and hypoxemia requiring vasopressor support and ICU admission. An echocardiogram showed left ventricular ejection fraction (EF) of 35% with hypokinesia. Due to persistent shock state and elevated inflammatory markers after 36 hours, we started him on methylprednisolone 1.5 mg/kg daily. After 24 hours, clinical status and inflammatory markers improved significantly. A follow-up echocardiogram four weeks after discharge showed normalization of EF. DISCUSSION: Since the beginning of the pandemic, different countries reported cases of a hyperinflammatory process in children that had features similar to atypical Kawasaki disease.(3) A larger study described MIS-C in 99 patients under 21 years of age in New York.(4) The case definition MIS-C was established by the CDC. For a time, it was unknown if this syndrome was specific to children or whether it also occurred in adults. A MIS-A working case definition includes five criteria: severe illness requiring hospitalization in a person aged at least 21 years;a positive test result for current or previous SARS-CoV-2 infection;severe dysfunction of one or more extrapulmonary organ systems;laboratory evidence of severe inflammation;and absence of severe respiratory illness.(2) Case definitions for MIS-C/A with degrees of diagnostic certainty have also been elaborated.(5) We are presenting a patient that meets clinical and laboratory criteria for MIS-A. His respiratory dysfunction occurred after admission when his inflammatory markers were already elevated. This case includes a temporal correlation after the initial peak of COVID-19 cases in Houston by 31 days. CONCLUSIONS: The number of cases of MIS-A is unclear. It is important to keep this condition in our differential in the context of recent SARS-CoV-2 infection for early identification and appropriate treatment to reduce further harm and mortality. REFERENCE #1: 1. Centers for Disease Control and Prevention. Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019 (COVID-19). Published online May 14, 2020. Accessed April 22, 2020. https://emergency.cdc.gov/han/2020/han00432.asp2. Morris SB, Schwartz NG, Patel P, et al. Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection — United Kingdom and United States, March–August 2020. MMWR Morb Mortal Wkly Rep. 2020;69(40):1450-1456. doi:10.15585/mmwr.mm6940e1 REFERENCE #2: 3. Verdoni L, Mazza A, Gervasoni A, et al. An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. The Lancet. 2020;395(10239):1771-1778. doi:10.1016/S0140-6736(20)31103-X4. Dufort EM, Koumans EH, Chow EJ, et al. Multisystem Inflammatory Syndrome in Children in New York State. N Engl J Med. 2020;383(4):347-358. doi:10.1056/NEJMoa2021756 REFERENCE #3: 5. Vogel TP, Top KA, Karatzios C, et al. Multisystem inflammatory syndrome in children and adults (MIS-C/A): Case definition & guidelines for data collectio , analysis, and presentation of immunization safety data. Vaccine. Published online February 2021:S0264410X21000931. doi:10.1016/j.vaccine.2021.01.054 DISCLOSURES: No relevant relationships by Luis Chug, source=Web Response No relevant relationships by Julin Mathew, source=Web Response No relevant relationships by Nora Moron Cabrera, source=Web Response No relevant relationships by Rohini Rao, source=Web Response No relevant relationships by Juan Salvatierra, source=Web Response
ABSTRACT
INTRODUCTION: Since the beginning of this year, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a pandemic which has affected the entire world. Researchers are still trying to understand the characteristics and treatment options. Clinical manifestations may differ between children and adults. In rare cases, however, pediatric patients can present with a severe life-threatening complication called Multisystem Inflammatory Syndrome in Children (MIS-C), a term recognized by the CDC on May 14. (2) METHODS: A 25-year-old Hispanic male who previously tested positive for SARS-CoV-2 presents to the ICU with 1 week of sore throat, dysphagia, fever, non-bloody diarrhea, conjunctivitis, and mild confusion. He also reported he had a positive SARS-CoV-2 test 6 weeks prior to admission. On physical examination, the patient was febrile and found to have tender submandibular lymph nodes, redness on the oropharynx. The laboratory at admission shows an increase in inflammatory markers. The COVID-19 RT-PCR test was negative, coronavirus IgG was positive, and a normal chest radiograph. On the third day of admission, the patient's clinical status required ICU admission due to increased lethargy, shortness of breath, hypotension, and hypoxemia requiring vasopressor support. Additional tests including toxicology screen, blood culture, urinalysis, Histoplasma antigen, cryptococcal, coccidioidomycosis IgM and IgG, Clostridium Difficile PCR were all negative. An echocardiogram showed left ventricular ejection fraction (EF) of 35% with some hypokinesia. CT scan of the chest with contrast showed no pulmonary embolism but mild pleural effusions with atelectasis. Due to lack of improvement, we decided to start him on methylprednisolone at 1.5 mg/kg daily. After 24 hours of starting steroids, the clinical status and inflammatory markers improved significantly. RESULTS: This is the first case report of Multisystem Inflammatory Syndrome (MIS) in a young adult with clear documentation of increase inflammatory markers. MISChildren can present at any time but often occurs 6- 51 days following infection. Until now, it was unknown if this syndrome was specific to children or if it also occurs in adults with COVID-19. We treated our patient with steroids, resulting in improvement on his clinical status.