MULTISYSTEM INFLAMMATORY INFLAMMATORY SYNDROME IN ADULTS (MIS-A) IN THE RETURNING TRAVELER

ABSTRACT

CASE A 27-year-old man presented with a one-day history of meningismus and fever six days after returning from Belize in the setting of COVID-19 infection 6 weeks prior to admission. On hospital day 3, he had persistent cyclical fevers and developed a non-pruritic erythematous maculopapular rash as well as conjunctival injection and diarrhea. Overnight (day 3-4), he developed chest pain and tachycardia;labs were remarkable for myocardial injury and elevated inflammatory markers. Emergent cardiac echo identified myopericarditis with LV ejection fraction of 20%. These constellation of symptoms in the setting of a recent COVID-19 infection were consistent with a diagnosis of multisystem inflammatory syndrome of adults (MIS-A). Pulse dose steroids and heart failure therapy were initiated;he had a rapid response to the treatment with cardiac MRI documenting partial recovery of his LVEF to 48% and resolved myocarditis after 4 days of therapy. IMPACT/DISCUSSION: MIS-A is a rare complication of the post-acute phase of COVID-19. As of June 2021, less than 150 cases had been published. The CDC criteria for MIS-A include age >21 hospitalized for >24 hours with a fever for >24 hours and with at least 1 primary criteria (severe cardiac illness OR rash and conjunctivitis) and 2+ secondary criteria (new neurological signs, unexplained shock, abdominal symptoms or thrombocytopenia). Lab criteria include A) a positive SARS CoV-2 test for current or recent infection and B) elevated levels of at least 2 inflammatory markers. A systematic review by Patel et al. highlighted key trends amongst MIS-A patients, including a median age of 21, male preference (70%), and lack of co-morbidities (58%) A majority presented with fever (96%), hypotension (60%), cardiac dysfunction (54%), and diarrhea (52%) In adults, conjunctivitis, rash, and cervical adenopathy were noted but less common. Although 97% of patients had positive serologic or RT-PCR tests, only 32% were positive for both during the hospitalization. Our patient possessed key demographic and clinical features associated with MIS-A. However, we initially prioritized the differential of fever in a returning traveler over empiric management of MIS-A. Nevertheless, early recognition of decompensation from MIS-A allowed for quick initiation of steroids and transfer to the ICU. The fulminant nature of this disease makes it an important diagnosis to include on the differential of acutely febrile young individuals with a history of COVID. CONCLUSION: MIS-A is a rare disease that can easily be confounded with other causes of inflammation;as a diagnosis of exclusion, delays in diagnosis can be expected. However, it's potential severity makes it a critical one to consider early in key patient populations. Increased awareness of cardinal symptoms and population trends can help clinicians consider MIS-A early in their clinical reasoning and facilitate early treatment. This is especially important in a world with an increasing incidence of COVID-19.