Encephalopathy and life-threatening gastrointestinal hemorrhage in a child with mis-c

ABSTRACT

INTRODUCTION: Multisystem Inflammatory Syndrome in Children (MIS-C) is a recently described phenomenon associated with Coronavirus Disease 2019 (COVID-19). Children typically present with fever and laboratory evidence of systemic inflammation. Additional signs and symptoms can vary widely, leading to diagnostic and management challenges. Given the range of clinical manifestations in children with MIS-C, it is important to report unique cases that represent uncommon but life-threatening complications associated with the disease and its management. DESCRIPTION A previously healthy 11 year old male was admitted to the pediatric ICU and diagnosed with MIS-C based on clinical appearance, laboratory pattern, and SARS-CoV-2 antibody profile. The patient presented with shock and neurologic symptoms including encephalopathy and dysarthria. The shock was relatively mild and consistent with the hemodynamic profile commonly seen with MIS-C. Brain MRI, obtained to rule out thromboembolic injury, demonstrated cytotoxic edema of the corpus callosum, an imaging finding similar in nature to several previous reports of MRI abnormalities in children with MIS-C. Following administration of intravenous immunoglobulin and pulse dose steroids, the patient convalesced and was discharged home. Medications prescribed at discharge included a steroid taper, aspirin, and proton pump inhibitor. Four days later, he was readmitted with shock and life threatening gastrointestinal hemorrhage. The patient required large scale resuscitation with vasoactive agents and over twice his own circulatory volume in blood products delivered by a rapid infusion system. After extensive evaluation of potential bleeding sources, angiography revealed active bleeding from two arterial vessels supplying the duodenum. The patient demonstrated no further bleeding following successful coil embolization of the two arteries. DISCUSSION: We hypothesize that the vasculitic nature of MIS-C combined with anti-inflammatory and anti-thrombotic therapy placed the patient at risk of hemorrhage. This case highlights unique radiologic features of MIS-C as well as potential complications of treatment and the disease process itself. To our knowledge, this is the first report of a child with life-threatening GI hemorrhage in the setting of MIS-C.