Prolonged fever and inflammation in a young child in the midst of the pandemic - it's not always MIS-C
American Journal of the Medical Sciences
; 365(Supplement 1):S390, 2023.
Article
in English
| EMBASE | ID: covidwho-2233295
ABSTRACT
Case Report Prolonged fever in children is a symptom that is seen in many different diseases, infections, malignancies, and autoimmune conditions. This can, at times, make the correct diagnosis challenging. A previously healthy 10-year-old male was transferred to our institution with one week history of fever, fatigue, abdominal pain, and vomiting. Laboratory studies demonstrated pancytopenia, transaminitis, electrolyte abnormalities, elevated pro-inflammatory markers & D-Dimer, and hypoalbuminemia. COVID-19 IgG was reactive. Due to the severity in presentation the patient was transferred to the ICU with a presumptive diagnosis of MIS-C. Hewas started on IVIG as well as a five-day course of high-dose methylprednisolone per protocol. Aspirin was added, but later discontinued, due to worsening thrombocytopenia. CT imaging with contrast showed small bilateral pleural effusions & periportal edema, mild splenomegaly, and echocardiogram showed diffuse dilation of the left main and left anterior descending arteries. Given the laboratory findings the differential diagnosis was expanded, Ehrlichia caffeensis serology was sent and empiric Doxycycline started. EBV Nuclear Antigen IgG antibody and EBV Viral Capsid Antigen IgM Antibody resulted as positive suggesting recent or reactivated infection. Respiratory viral PCR with COVID-19, Cytomegalovirus and Parvovirus PCR were negative. Despite initial treatment, the patient continued to have persistent fever, severe pancytopenia, and high ferritin up to 24 426 ng/mL, raising suspicion for Haemophagocytic Lymphohistiocytosis (HLH). Soluble interleukin-2 level was elevated & his presentation was then considered to be more consistent with HLH given that he met 6/8 criteria. Screening for primary HLH including CD107a, perforin and granzyme B, SAP, and XIAP resulted in the latter three being normal but CD107a was abnormal. Next generation sequencing for primary criteria was negative. E. Chaffeensis resulted positive IgM 180, IgG 1256. MIS-C and HLH have overlapping features but differ in some clinical manifestations. Timely recognition and management is paramount as the management differs. This case illustrates the importance of performing a broad search for potential causes, allowing for appropriate and timely treatment. COVID-19 serology alone should not be the basis for diagnosis of MIS-C in a patient with fever and inflammation. This is important as SARS-CoV2 becomes endemic. Infections such as EBV and Ehrlichiosis should be on the differential particularly in endemic areas and during seasons of higher prevalence for the latter, as these have been well documented to cause HLH. Copyright © 2023 Southern Society for Clinical Investigation.
abdominal pain; case report; child; clinical article; conference abstract; coronavirus disease 2019; Cytomegalovirus; diagnosis; differential diagnosis; drug megadose; drug therapy; echocardiography; edema; Ehrlichia; ehrlichiosis; fatigue; ferritin blood level; fever; gene expression; hemophagocytic syndrome; high throughput sequencing; human; hypertransaminasemia; hypoalbuminemia; inflammation; left anterior descending coronary artery; male; nonhuman; pancytopenia; pandemic; Parvoviridae; pediatric multisystem inflammatory syndrome; pleura effusion; prevalence; school child; season; serology; Severe acute respiratory syndrome coronavirus 2; splenomegaly; thrombocytopenia; vomiting; acetylsalicylic acid; cell nucleus antigen; D dimer; doxycycline; electrolyte; endogenous compound; ferritin; granzyme B; human immunoglobulin; immunoglobulin G; immunoglobulin G antibody; immunoglobulin G1; immunoglobulin M; immunoglobulin M antibody; interleukin 2; lysosome associated membrane protein 1; methylprednisolone; perforin; virus capsid antigen
Full text:
Available
Collection:
Databases of international organizations
Database:
EMBASE
Type of study:
Diagnostic study
/
Observational study
/
Prognostic study
Topics:
Long Covid
Language:
English
Journal:
American Journal of the Medical Sciences
Year:
2023
Document Type:
Article
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