A case of multi-system inflammatory syndrome in children presenting as acute cervical lymphadenitis

ABSTRACT

Case Report Multi-system inflammatory syndrome in children (MIS-C) is a recently described clinical syndrome in children that continues to progress in its manifestations. The syndrome is associated with the novel coronavirus disease 2019 (COVID-19), and can affect any organ system in the body, leading to a wide variety of symptoms. This syndrome is often misdiagnosed in its initial presentation, and many families require multiple evaluations before finally being diagnosed and admitted for the appropriate treatment. Symptoms are caused by overwhelming inflammation and often involve the gastrointestinal, integumentary, cardiac, and hematologic systems. A high index of suspicion at the time of initial presentation should be maintained to obtain an accurate diagnosis of MIS-C. Patient Case We report the case of a previously healthy 11-year-old male who presents with acute cervical lymphadenitis that did not respond to appropriate outpatient antibiotic therapy. He has a history of testing positive for SARS-CoV-2 via PCR, associated with mild cough and rhinorrhea, about three weeks prior to the onset of current symptoms. Upon initial presentation physical exam and laboratory results were not consistent with MIS-C, however inflammatory markers were slightly elevated which was consistent with a diagnosis of cervical lymphadenitis. Over the course of the next several days, the patient developed gastrointestinal symptoms including abdominal pain, vomiting and diarrhea. He also developed non-purulent conjunctivitis, and a generalized erythematous rash, associated with significant leukocytosis, transaminitis, and elevated coagulation markers. His electrocardiogram (EKG), and echocardiogram (ECHO) remained within normal limits despite elevated pro-BNP levels, and he later developed significant hypotension, hypoxemia, and bilateral pleural effusions requiring a short course of diuretics. The patient remained febrile despite receiving a normal saline bolus, treatment with intravenous immune globulin (IVIG), and intravenous steroids. He had ongoing symptoms, and the erythematous rash reappeared. His steroid dose was increased, and the patient had a good response in both labs, and clinical status. Leukocytosis has continued, but there is significant improvement in all other inflammatory markers, and the patient is on course to be discharged home safely. Conclusion Many patients are unfortunately misdiagnosed after multiple evaluations before the final diagnosis of MIS-C is made. Multi-system inflammatory syndrome in children (MISC) may mimic other conditions such as gastroenteritis, acute appendicitis, Kawasaki Disease, sepsis, or even lymphadenitis. Clinicians should be alert to subtle signs of inflammation, such as lymphadenitis, that may progress to more classic symptoms of MIS-C such as persistent fever, abdominal pain, and a rash.