COVID-19 MULTISYSTEM INFLAMMATORY SYNDROME IN A YOUNG ADULT: RAPID REVERSAL OF CARDIOGENIC SHOCK WITH IVIG AND STEROIDS

ABSTRACT

SESSION TITLE Cardiovascular Complications in Patients with COVID-19 SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/19/2022 1245 pm - 145 pm INTRODUCTION: Multisystem inflammatory syndrome in adults (MIS-A) is a hyperinflammatory condition characterized by fever, elevated inflammatory markers, and multi-organ dysfunction, including severe cardiac illness, neurological and gastrointestinal symptoms, mucocutaneous involvement, and thrombocytopenia usually 2-5 weeks after COVID-19 infection (1). There are currently no guidelines for the management of this novel syndrome. CASE PRESENTATION A 20-year-old obese male presented for 3 days of fatigue, fever, dyspnea, diarrhea, and worsening encephalopathy. He tested positive for COVID-19 3 weeks prior and experienced 4 days of mild symptoms. He had received 2 doses of Moderna mRNA vaccine 9 months prior. On presentation, he had a GCS of 3. He was febrile, hypotensive, tachycardic, not hypoxic, and found to have non-purulent conjunctivitis but no rash. He was intubated for airway protection and started on norepinephrine (NE) shortly after arrival. Labs revealed positive COVID-19 PCR, lactate of 5.6 mmol/L, elevated hs-troponin which peaked at 11,300 ng/L, D-Dimer 12,574 ng/ml, ferritin >16,500 ng/ml, CRP 224 mg/L, platelet count 18 x109/L. EKG showed sinus tachycardia without ST changes. CT chest/abdomen/pelvis was unremarkable. The patient was given broad-spectrum antibiotics and admitted to ICU. An echocardiogram (echo) showed global hypokinesis with an ejection fraction of 10-15%. Right heart catheterization found a wedge pressure of 23 mmHg, and a cardiac index of 1.4 L/min/m2. NE was weaned, and dobutamine and bumetanide drips were started. Infectious disease was consulted and diagnosed the patient with MIS-A. Treatment was started with methylprednisolone 2mg/kg/day and IVIG (2 g/kg x2 days). 48 hours later, dobutamine was able to be discontinued and follow-up echo showed normalization of biventricular systolic function. Steroids were continued for 7 days before tapering off. The patient’s presenting symptoms, platelets, and inflammatory markers rapidly improved, and he was ultimately able to be discharged home. DISCUSSION: MIS-A is a rare but serious extrapulmonary sequela of COVID-19 which can cause critical illness including cardiogenic shock. The long-term consequences of MIS-A are not known, but fortunately, as demonstrated by our case, severe cardiac dysfunction can be effectively reversed with timely diagnosis and initiation of immunosuppressive treatment. This recovery was achieved without immunomodulators (eg tocilizumab) which have been used in other MIS-A cases (2). MIS-A should be considered in patients with severe cardiac dysfunction and evidence of systemic inflammation even with no known history of COVID as this can develop after mild or even asymptomatic COVID-19 infections. CONCLUSIONS: Immunosuppressive therapies can rapidly reverse severe multiorgan dysfunction in MIS-A. Still, further study is needed to identify at-risk patients and create definitive treatment guidelines. Reference #1 Vogel TP, Top KA, Karatzios C, et al. Multisystem inflammatory syndrome in children and adults (MIS-C/A) Case definition & guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine. 2021;39(22)3037-3049. doi10.1016/j.vaccine.2021.01.054 Reference #2 Patel P, DeCuir J, Abrams J, Campbell AP, Godfred-Cato S, Belay ED. Clinical Characteristics of Multisystem Inflammatory Syndrome in Adults A Systematic Review. JAMA Netw Open. 2021;4(9)e2126456. doi10.1001/jamanetworkopen.2021.26456 DISCLOSURES No relevant relationships by Christopher Allison no disclosure on file for Sandeep Arepally;No relevant relationships by Amad Chohan No relevant relationships by Albert Manudhane No relevant relationships by Griffin Reed