MULTISYSTEM INFLAMMATORY SYNDROME OF ADULTS: A RARE COMPLICATION AFTER COVID-19 INFECTION

ABSTRACT

SESSION TITLE Unique Inflammatory and Autoimmune Complications of COVID-19 Infections 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 rare but clinically significant complication of COVID-19 infection characterized by severe illness with extrapulmonary organ dysfunction, markedly elevated inflammatory markers in the absence of severe respiratory illness or other obvious source of infection (1). We present a case of a 37-year-old male, with negative infectious evaluation and marked clinical improvement after administration of IVIG. CASE PRESENTATION We present a 37-year-old black male with a past medical history of type 2 diabetes who was admitted to the hospital with shock and organ failure;prior to his presentation, he was diagnosed with COVID-19 pneumonia requiring outpatient therapy. On presentation, he was tachycardic, febrile, hypotensive with significant renal failure and lactic acidosis;inflammatory markers were elevated (CRP 640, ESR 108). Imaging was significant for mediastinal and hilar lymphadenopathy, with clear parenchyma (Figure 1). Broad coverage antibiotics, vasopressors, and stress dose steroids were initiated. Infectious evaluation was unrevealing with negative blood, urine, and sputum cultures;Echocardiogram revealed LVEF of 40% with mild RV dysfunction. His renal failure worsened, requiring CRRT. Vasculitis evaluation with ANA, ANCA, MPO, PR3, GBM, HIV, C3-C4 and cryoglobulins returned normal. Eventually, the patient was weaned from vasopressor support on hospital day four. Trials of weaning steroids resulted in recurrence of fevers and increasing vasopressor support. Given continued fevers without obvious infection there were concerns for MIS-A occurring shortly after COVID-19 infection. Antibiotics were discontinued and he received 2g/kg of IVIG with marked clinical improvement and was rapidly weaned from vasopressor support. We initiated methylprednisolone 1 mg/kg twice daily with steroid taper. He had improvement in inflammatory markers after IVIG and high dose steroids (CRP-6.7, ESR-49 prior to discharge). DISCUSSION: MIS-A is a rare disease that occurs after COVID-19 infection, with few reported cases in literature. Presentation is variable, but symptoms include high fever, dyspnea, lethargy, myalgias, and a diffuse maculopapular rash. Notably, hypoxia is not a prominent feature, a significant distinction from classic COVID-19 infection. Patel et al noted a predominance in young adults, males, and non-Hispanic black or Hispanic persons (2). The proposed mechanism stems from dysregulated immune response, with abnormal interferon production which drives macrophage activation and organ damage (3). There are no treatment guidelines available, and treatment of MIS-A is extrapolated from MIS-C and includes immunomodulatory therapies with IV IG, IL-1 receptor antagonist, and methylprednisolone. CONCLUSIONS: Prompt recognition of MIS-A critical given its potential for significant multi-organ dysfunction. Reference #1 Centers for Disease Control and Prevention. Multisystem Inflammatory Syndrome in Adults (MIS-A) Case Definition Information for Healthcare Providers. Available at Multisystem Inflammatory Syndrome in Adults (MIS-A) Case Definition Information for Healthcare Providers (cdc.gov). Accessed 3/19/2022 Reference #2 Patel, P., Decuir, J., Abrams, J., Campbell, A. P., Godfred-Cato, S., & Belay, E. D. (2021). Clinical Characteristics of Multisystem Inflammatory Syndrome in Adults A Systematic Review. In JAMA Network Open (Vol. 4, Issue 9). https//doi.org/10.1001/jamanetworkopen.2021.26456 Reference #3 Weatherhead, J. E., Clark, E., Vogel, T. P., Atmar, R. L., & Kulkarni, P. A. (2020). Inflammatory syndromes associated with SARS-cov-2 infection Dysregulation of the immune response across the age spectrum. Journal of Clinical Investigation, 130(12). https//doi.org/10.1172/JCI145301 DISCLOSURES No relevant relationships by Mohammed Al-Charakh No relevant relationships by John Pare t no disclosure on file for Maximiliano Tamae Kakazu;