A case of multisystem inflammatory syndrome and shock after COVID-19 in an adult

ABSTRACT

INTRODUCTION: We describe a case of a critically ill adult patient with a history of COVID-19 who presents with new cardiomyopathy, fever, and rash. He was successfully treated with IVIg and corticosteroids with immediate and dramatic improvement in cardiac function and fever. We propose the post-COVID-19 inflammatory syndrome affects adults though it has been widely reported in children. METHODS: A 42-year-old male with no known past medical history presented to our hospital with three days of fevers, a diffuse rash, bilateral conjunctivitis, diarrhea, and worsening encephalopathy. On arrival, he was febrile to 105F and hypotensive to 88/61 mmHg despite fluid resuscitation. The patient had no medical history. He was admitted to the medical intensive care unit and treated with norepinephrine for shock and treated with broad spectrum antibiotics. Transthoracic echocardiography showed severely reduced LV systolic function. EKG showed sinus tachycardia at 142BPM without ST-segment abnormality. Labs showed thrombocytopenia, lymphopenia, hyponatremia, and elevated C-reactive protein. He was admitted to our intensive care unit for presumed septic shock requiring norepinephrine. PCR testing for COVID-19 was negative but on day three, the patient reported a history of COVID-19 one month ago. His COVID-19 antibody test was positive. On day four he received 1mg/kg of IVIg, 1mg/kg of intravenous methylprednisolone BID, and 81mg of aspirin daily. This treatment course was based on our children's hospital's protocol for treating children with MIS-C. After 24 hours of treatment, the patient was afebrile and his LV dysfunction and encephalopathy had totally resolved. RESULTS: Several syndromes have been ascribed to COVID-19, including pneumonia, myocardial injury, thrombosis, and renal failure. A separate entity has been described after COVID-19 in children, MIS-C. This syndrome, considered a post-infectious inflammatory state, shares many similarities with Kawasaki Disease and there are several reports of treatment with IVIg and steroids. Our patient was successfully treated using the protocol developed at our children's hospital for MIS-C. A multisystem inflammatory syndrome that mimics KD can occur after COVID-19 in adults. This presumed vasculitis can cause myocardial dysfunction and shock.