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1.
Front Med (Lausanne) ; 9: 835421, 2022.
Article in English | MEDLINE | ID: covidwho-2099159

ABSTRACT

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection causes a disease (COVID-19) with multisystem involvement. The world is now entering a phase of post-COVID-19 manifestations in this pandemic. Secondary hemophagocytic lymphohistiocytosis (sHLH) is a life-threatening hyperinflammatory event triggered by viral infections, including SARS-CoV-2. Both Multisystem Inflammatory Syndrome-Adults (MIS-A) and Cytokine Storm Syndrome (CSS) are considered close differentials of sHLH and add to the spectrum of Post-acute COVID-19 syndrome (PACS). In this report, we presented the case of a middle-aged Asian man who was initially discharged upon recovery from severe COVID-19 infection after 17 days of hospitalization to a private institute and later came to our hospital 13 days post-discharge. Here, he was diagnosed with sHLH, occurring as an extension of CSS, with delayed presentation falling within the spectrum of PACS. The diagnosis of sHLH was made holistically with the HLH-2004 criteria. Our patient initially responded to intravenous immunoglobulin (IVIG) and dexamethasone, later complicated by disseminated Candida auris infection and had a fatal outcome. Though many cases of HLH during active COVID-19 and a few cases post COVID-19 recovery have been reported, based on H-score, which has limitations as a diagnostic tool. We report the first case report of post-COVID-19 sHLH using the HLH-2004 criteria, complicated by disseminated Candidemia, emphasizing that the care of patients with COVID-19 does not conclude at the time of hospital discharge. We highlight the importance of surveillance in the post-COVID phase for early detection of sHLH which may predispose to fatal opportunistic infections (OIs).

2.
J Community Hosp Intern Med Perspect ; 12(4): 7-13, 2022.
Article in English | MEDLINE | ID: covidwho-2081653

ABSTRACT

Multisystem inflammatory syndrome is a life-threatening condition associated with elevated inflammatory markers and multiple organ injury. A diagnosis of exclusion, it has been reported after severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2) in children and adults; recently it has been described in some post-COVID-19 vaccinated individuals. The prognosis with supportive care and immunomodulatory therapy is good, although some individuals may require treatment in the intensive care unit (ICU). Here we report a case of a 58-year-old man who developed multi-organ failure after receiving the second dose of the Moderna mRNA-1273 COVID-19 vaccine. He required critical organ support in the ICU. An extensive workup was done to rule out alternative infectious and inflammatory processes. Following a period of gradual in-hospital convalescence, our patient made a full recovery. To our knowledge, this is the first comprehensively described case of multisystem inflammatory syndrome associated with Moderna mRNA-1273 COVID-19 vaccine in an adult over 50 years of age.

4.
Ann Med Surg (Lond) ; 81: 104309, 2022 Sep.
Article in English | MEDLINE | ID: covidwho-2041486

ABSTRACT

Introduction: and importance: Systemic capillary leak syndrome (SCLS) and multisystem inflammatory syndrome in adults (MIS-A) are very rare multifactorial etiology disorders associated with COVID-19 infection. Both conditions are thought to be manifested by the inflammatory state induced by COVID-19 infection. Recurrent COVID-19-associated concomitant/successive manifestations of both disorders have not been reported yet. Case presentation: We report a 38-year-old Asian gentleman who presented initially with fever, cough, shortness of breath, body aches, dizziness, and epigastric pain due to COVID-19 infection. A few days before this presentation, the same patient developed multisystem inflammatory syndrome in adults (MIS-A). Later, based on clinical and laboratory investigations, he was diagnosed with new-onset systemic capillary leak syndrome (SCLS). Despite resuscitative measures, the patient passed away. Clinical discussion: The increased risk of inflammatory complications associated with COVID-19 infection is an emerging concern. Our case report signifies the importance of COVID-19 awareness in less educated and underserved areas with fewer information resources. Rare and fatal manifestations should also be advertised and discussed with the general masses with equal emphasis. Conclusion: This case signifies the importance of understanding the pathophysiology of new-onset systemic capillary leak syndrome in a patient with recurrent COVID-19 infection and utilizing clinical knowledge and decision-making to manage such rare and complex disorders.

5.
Cureus ; 14(7): e27353, 2022 Jul.
Article in English | MEDLINE | ID: covidwho-2025379

ABSTRACT

Multisystem inflammatory syndrome in adults (MIS-A) is a systemic inflammatory syndrome that presents with a heterogeneous collection of signs and symptoms in adults. Here we present a case of a 38-year-old male who met the case definition of the MIS-A four weeks after a mild, symptomatic case of coronavirus disease 2019 (COVID-19) despite receiving casirivimab-imdevimab (REGEN-COV). Given the presence of signs and symptoms consistent with MIS-A, the patient was started on intravenous immune globulin (IVIG) and IV methylprednisolone. He promptly demonstrated clinical improvement over the next several days.

6.
Clin Infect Dis ; 2021 Nov 28.
Article in English | MEDLINE | ID: covidwho-2017777

ABSTRACT

BACKGROUND: Multisystem inflammatory syndrome in adults (MIS-A) was reported in association with the COVID-19 pandemic. MIS-A was included in the list of adverse events to be monitored as part of the emergency use authorizations issued for COVID-19 vaccines. METHODS: Reports of MIS-A patients received by the Centers for Disease Control and Prevention (CDC) after COVID-19 vaccines became available were assessed. Data collected on the patients included clinical and demographic characteristics and their vaccine status. The Vaccine Adverse Events Reporting System (VAERS) was also reviewed for possible cases of MIS-A. RESULTS: From December 14, 2020 to April 30, 2021, 20 patients who met the case definition for MIS-A were reported to CDC. Their median age was 35 years (range, 21-66 years), and 13 (65%) were male. Overall, 16 (80%) patients had a preceding COVID-19-like illness a median of 26 days (range 11-78 days) before MIS-A onset. All 20 patients had laboratory evidence of SARS-CoV-2 infection. Seven MIS-A patients (35%) received COVID-19 vaccine a median of 10 days (range, 6-45 days) before MIS-A onset; 3 patients received a second dose of COVID-19 vaccine 4, 17, and 22 days before MIS-A onset. Patients with MIS-A predominantly had gastrointestinal and cardiac manifestations and hypotension or shock. CONCLUSIONS: Although 7 patients were reported to have received COVID-19 vaccine, all had evidence of prior SARS-CoV-2 infection. Given the widespread use of COVID-19 vaccines, the lack of reporting of MIS-A associated with vaccination alone, without evidence of underlying SARS-CoV-2 infection, is reassuring.

7.
IDCases ; 30: e01606, 2022.
Article in English | MEDLINE | ID: covidwho-2004125

ABSTRACT

COVID-19 vaccines are generally proven safe in all population and are highly recommended. However, rare adverse events have been reported. We hereby present a case of an 18-year-old man who presented to emergency department with fever, meningitis like symptoms, shortness of breath, chest pain, skin rash, and extreme fatigue. He had cardiac manifestations including hypotension, elevated troponin, and reduced ejection fraction. High inflammatory markers were also noted. He was initially worked up for and treated as a possible infectious etiology, but the microbiological studies were negative and there was no response to treatment. Since he had recently received booster dose of Pfizer-BioNTech COVID-19 vaccination three weeks prior to onset of symptoms, a possibility of Multisystem inflammatory syndrome in children (MIS-C) was made. His presentation fulfilled all the diagnostic criteria. The possibility for MIS-C being related to vaccination was proposed after relevant serological tests showed that the antibodies, he had were due to COVID-19 vaccine, not to a prior infection. After he received appropriate immunomodulatory treatment (IVIG and methylprednisolone) as per the guideline, he showed marked clinical improvement. Our case report highlights the need to consider MIS-C as a potential differential in young patients who present with unexplained multisystem illness with increased inflammatory markers and negative microbiologic work-up. MIS-C can be secondary to COVID-19 vaccination as well as to prior COVID-19 infection.

8.
Cureus ; 14(4): e24438, 2022 Apr.
Article in English | MEDLINE | ID: covidwho-1954918

ABSTRACT

Introduction Classification criteria and practice guidelines for inpatient management of multisystem inflammatory syndrome (MIS) exist, but reports on outpatient management and clinical outcomes are lacking. Here we describe the management and clinical outcomes of four children and four adults with MIS seen at Walter Reed National Military Medical Center (WRNMMC) from diagnosis to six months follow-up. Methods This retrospective, case-series describes the initial presentation and management of MIS in four children and four adults seen at WRNMMC from March 2020 to September 2021. Data on each patient was collected from the time of exposure to the SARS-CoV-2 virus to six months post-diagnosis with MIS. Extracted data includes: demographics, comorbidities, initial MIS presentation, inpatient treatment, outpatient treatment, and clinical outcomes. Results A total of 62.5% of patients presented in shock. All pediatric patients received IVIG, methylprednisolone, and anakinra; no adult received this combination. Steroids and immunomodulatory medications were discontinued in 1-2 months outpatient. Three children and two adults had full symptomatic resolution. One child and two adults had persistent deconditioning at six months follow-up. One adult had persistent dyspnea. Conclusions MIS appears to be monophasic with no recurrences at six months follow-up in our patients who only required 1-2 months of glucocorticoid or immunomodulatory medications. The better outcomes in children raise the question of how much of this difference can be attributed to early combination therapy versus physiologic differences in children and adults.

9.
Infectious Diseases in Clinical Practice ; 30(4):5, 2022.
Article in English | Web of Science | ID: covidwho-1886473

ABSTRACT

Multisystem inflammatory syndrome in adults presents with extrapulmonary organ dysfunction in patients with a recent COVID-19 infection. A 22-year-old man with a history of ataxia with vitamin E deficiency and recent asymptomatic COVID-19 infection presented with retropharyngeal edema treated as phlegmon. He developed cardiac dysfunction and required vasopressor support with evidence of high inflammatory markers. Multisystem inflammatory syndrome in adults was diagnosed, and he rapidly improved with intravenous (IV) corticosteroids. Multisystem inflammatory syndrome in adults can rarely present with retropharyngeal phlegmon. We identified 2 reported cases in adults and 5 in children with an age range of 4 to 51 years. COVID-19 infection was established in all cases but was often previously unknown. All patients recovered with IV corticosteroids with or without IV immunoglobulin. In conclusion, multisystem inflammatory syndrome in adults can present with retropharyngeal edema, and previous COVID-19 infection may not be apparent.

10.
Pathogens ; 11(5)2022 May 08.
Article in English | MEDLINE | ID: covidwho-1862869

ABSTRACT

The novel coronavirus SARS-CoV-2, which has similarities to the 2002-2003 severe acute respiratory syndrome coronavirus known as SARS-CoV-1, causes the infectious disease designated COVID-19 by the World Health Organization (Coronavirus Disease 2019). Although the first reports indicated that activity of the virus is centered in the lungs, it was soon acknowledged that SARS-CoV-2 causes a multisystem disease. Indeed, this new pathogen causes a variety of syndromes, including asymptomatic disease; mild disease; moderate disease; a severe form that requires hospitalization, intensive care, and mechanical ventilation; multisystem inflammatory disease; and a condition called long COVID or postacute sequelae of SARS-CoV-2 infection. Some of these syndromes resemble previously described disorders, including those with no confirmed etiology, such as Kawasaki disease. After recognition of a distinct multisystem inflammatory syndrome in children, followed by a similar syndrome in adults, various multisystem syndromes occurring during the pandemic associated or related to SARS-CoV-2 began to be identified. A typical pattern of cytokine and chemokine dysregulation occurs in these complex syndromes; however, the disorders have distinct immunological determinants that may help to differentiate them. This review discusses the origins of the different trajectories of the inflammatory syndromes related to SARS-CoV-2 infection.

11.
Clin Med (Lond) ; 22(3): 266-270, 2022 05.
Article in English | MEDLINE | ID: covidwho-1856279

ABSTRACT

Infection with SARS-CoV-2 may trigger a delayed hyper-inflammatory illness in children called paediatric multisystem inflammatory syndrome temporally associated with COVID-19 (PIMS-TS). A similar syndrome is increasingly recognised in adults termed multisystem inflammatory syndrome in adults (MIS-A) and may present acutely to medical or surgical specialties with severe symptoms, such as acute abdominal pain or cardiogenic shock. No national guidelines exist in the UK for the management of MIS-A and there is limited evidence to guide treatment plans. We undertook a national Delphi process to elicit opinions from experts in hyperinflammation about the diagnosis and management of MIS-A with the dual aim of improving recognition and producing a management guideline. Colleagues in paediatrics successfully initiated a national consensus management document that facilitated regional multidisciplinary referral and follow-up pathways for children with PIMS-TS, and we propose a similar system be developed for adult patients across the UK. This would facilitate better recognition and treatment of MIS-A across the multiple specialties to which it may present as well as enable follow-up with specialty services post-discharge.


Subject(s)
COVID-19 , Aftercare , COVID-19/complications , COVID-19/therapy , Child , Humans , Patient Discharge , SARS-CoV-2 , Systemic Inflammatory Response Syndrome/diagnosis , Systemic Inflammatory Response Syndrome/therapy , United Kingdom
12.
Cureus ; 14(4): e24042, 2022 Apr.
Article in English | MEDLINE | ID: covidwho-1847663

ABSTRACT

Multisystem inflammatory syndrome (MIS) after a primary infection with coronavirus disease 2019 (COVID-19) was first recognized in 2020 and presents with similar symptoms as Kawasaki disease, toxic shock syndrome, and macrophage activation syndrome/secondary hemophagocytic lymphohistiocytosis. In children, it is called multisystem inflammatory syndrome in children (MIS-C); in adults, it is termed multisystem inflammatory syndrome in adults (MIS-A). This case offers a unique presentation of MIS in a 20-year-old young adult, who turned 21 years old one week after his presentation. He fits the criteria for MIS-C and MIS-A according to the Centers for Disease Control and World Health Organization, respectively. Initial symptoms in the emergency department included headache, neck stiffness, and fever with diffuse rash. Other symptoms consistent with MIS-C/A developed rapidly later during the course of the disease.

13.
Cureus ; 14(3): e23440, 2022 Mar.
Article in English | MEDLINE | ID: covidwho-1835781

ABSTRACT

COVID-19 is a respiratory illness with multiple extra-pulmonary complications. The multisystem inflammatory syndrome (MIS) is one of its complications that usually affects children and is known as MIS-C, but several cases have been reported in adults, symbolized by MIS-A. Thus, the Centers for Disease Control and Prevention (CDC) developed a working case definition of MIS-A, which includes several criteria. Here we report two cases of adult male patients with clinical and laboratory symptoms consistent with MIS-A. Case one patient presented at a late stage after two weeks post the onset of symptoms. His health deteriorated rapidly, and eventually, he passed away. However, the second patient presented a few days after the symptoms' onset and took a course of steroids. He was discharged home.

14.
Indian J Crit Care Med ; 26(4): 532, 2022.
Article in English | MEDLINE | ID: covidwho-1818516

ABSTRACT

How to cite this article: Arjun R, Niyas VKM, Thomas S, Muralidharan R, Thomas A, Wilson AP, et al. MIS-C/A/V: There is More to It than Meets the Eye! Indian J Crit Care Med 2022;26(4):532.

15.
Clin Infect Dis ; 2022 Apr 20.
Article in English | MEDLINE | ID: covidwho-1806307

ABSTRACT

BACKGROUND: Multisystem inflammatory syndrome in adults (MIS-A) is a severe condition temporally associated with SARS-CoV-2 infection. METHODS: In this retrospective cohort study, we applied the U.S. Centers for Disease Control and Prevention (CDC) case definition to identify diagnosed and undiagnosed MIS-A cases among adults discharged April 2020-January 2021 from four Atlanta, Georgia hospitals affiliated with a single medical center. Non-MIS-A COVID-19 hospitalizations were identified using International Classification of Diseases, Tenth Revision encounter code U07.1. We calculated the ratio of MIS-A to COVID-19 hospitalizations, compared demographic characteristics of the two cohorts, and described clinical characteristics of MIS-A patients. RESULTS: We identified 11 MIS-A cases, none of which were diagnosed by the treatment team, and 5,755 COVID-19 hospitalizations (ratio 1: 523). Compared with patients with COVID-19, patients with MIS-A were more likely to be younger than 50 years (72.7% vs. 26.1%, p < 0.01) and to be non-Hispanic Black persons (81.8% vs. 50.0%, p = 0.04). Ten patients with MIS-A (90.9%) had at least one underlying medical condition. Two MIS-A patients (18.2%) had a previous episode of laboratory-confirmed COVID-19, occurring 37 and 55 days prior to admission. All MIS-A patients developed left ventricular systolic dysfunction. None had documented mucocutaneous involvement. All required intensive care, all received systemic corticosteroids, eight (72.7%) required mechanical ventilation, two (18.2%) required mechanical cardiovascular circulatory support, and none received intravenous immunoglobulin. Two (18.2%) died or were discharged to hospice. CONCLUSIONS: MIS-A is severe but likely underrecognized complication of SARS-CoV-2 infection. Improved recognition of MIS-A is needed to quantify its burden and identify populations at highest risk.

16.
JAAD Case Rep ; 23: 38-41, 2022 May.
Article in English | MEDLINE | ID: covidwho-1778277
17.
Cureus ; 14(2): e22614, 2022 Feb.
Article in English | MEDLINE | ID: covidwho-1776620

ABSTRACT

Hyperinflammation is a key component of severe coronavirus disease 2019 (COVID-19) and is associated with poor outcomes. It is imperative to distinguish severe COVID-19 from hyperinflammatory syndromes such as multisystem inflammatory syndrome (MIS) and hemophagocytic lymphohistiocytosis. There is a subset of post-COVID-19 patients who present with some symptoms characteristic of MIS in adults (MIS-A) yet do not meet all the criteria for a diagnosis. We describe the unique case of a patient with this kind of presentation who clinically improved following tocilizumab and corticosteroid usage.

18.
BMC Infect Dis ; 22(1): 300, 2022 Mar 28.
Article in English | MEDLINE | ID: covidwho-1765440

ABSTRACT

BACKGROUND: Severe inflammation and one or more extrapulmonary organ dysfunctions have been reported and this clinical picture is defined as "multisystem inflammatory syndrome in adults" (MIS-A) in severe coronavirus disease-2019 (COVID-19). We aimed to determine the effect of LDH/lymphocyte ratio (LLR) on the development of MIS-A. METHODS: The data of 2333 patients were retrospectively analyzed. RESULTS: MIS-A rate was found to be 9.9% and MIS-A related mortality was 35.3%. LRR level above 0.24 was found to predict MIS-A development with 70% sensitivity and 65.2% specificity. The risk of MIS-A development was found to be 3.64 times higher in those with LRR levels above 0.24 compared to those with 0.24 and below. In patients with MIS-A, LRR level above 0.32 predicts mortality with 78% sensitivity and 70% specificity. CONCLUSIONS: Early detection of MIS-A with high sensitivity and specificity in a practical ratio is very important in terms new studies.


Subject(s)
COVID-19 , Malnutrition , Adult , Humans , Inflammation/diagnosis , Malnutrition/diagnosis , Retrospective Studies , Systemic Inflammatory Response Syndrome
19.
Emerg Infect Dis ; 28(5): 1017-1020, 2022 05.
Article in English | MEDLINE | ID: covidwho-1760188

ABSTRACT

We observed multisystem inflammatory syndrome in 2 older adults in the United States who had received mRNA coronavirus disease vaccine soon after natural infection. We identified 5 similar cases from the Vaccine Adverse Events Reporting System. The timing of vaccination soon after natural infection might have an adverse effect on the occurrence of vaccine-related systemic inflammatory disorders.


Subject(s)
COVID-19 , Drug-Related Side Effects and Adverse Reactions , Aged , COVID-19/prevention & control , COVID-19 Vaccines/adverse effects , Humans , SARS-CoV-2 , United States , Vaccination/adverse effects
20.
Cureus ; 14(2): e22640, 2022 Feb.
Article in English | MEDLINE | ID: covidwho-1726761

ABSTRACT

Multisystem inflammatory syndrome (MIS) in adults associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is increasingly reported in published literature, although published reports remain sparse. In this report, we describe our first experience with a 31-year-old Caucasian male who developed severe MIS 31 days after a mild SARS-CoV-2 infection. The patient developed fever, elevated C-reactive protein (CRP), procalcitonin (PCT), reduced ejection fraction (EF), and shock. After extensive diagnostic work-up, nothing was found to justify his shock manifestation. A similar treatment to MIS in children (MIS-C) with immunoglobulins, corticosteroids, and anticoagulants led to a remarkable clinical improvement. MIS in adults (MIS-A) can be fatal. The early identification of MIS plays a crucial role in the prompt initiation of suitable treatment. Therefore, differential diagnosis and exclusion of other causes of illness are of priority. We believe that MIS in children treatment guidelines can be reformed in a way to include MIS in adults as well.

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