Abstract

Background: A growing number of reports from around the world has described a severe inflammatory syndrome in children similar to Kawasaki’s disease. This syndrome has been named multisystem inflammatory syndrome in children (MIS-C). There have been anecdotal reports of MIS-C-like illness in young adults in their early twenties as well. We present the case of a healthy 33-year-old woman who developed coronavirus disease 2019 (COVID-19) with clinical characteristics resembling MIS-C, a rare form of COVID-19 described primarily in children under 21 years of age. Case presentation: The patient presented with abdominal pain, loose motions, difficulty in breathing since 3 days and fever since 1 day. She was otherwise healthy, with no prior medical history. Her hospital course was notable for leukocytosis, bradycardia, acute heart failure (myocarditis) and pulmonary edema. MIS-C like illness secondary to COVID-19 was suspected due to presentation of myocarditis, bradyarrhythmia and pulmonary edema. She improved after giving IV steroids, diuretics, anticoagulation and supportive care and was discharged on hospital Day 5. Conclusion: MIS-C like illness should be considered in adults presenting with atypical clinical findings and concern for COVID-19. Further research is needed to support the role of IVIG and aspirin in this patient population.

Introduction

Coronavirus disease 2019 (COVID-19) is increasingly recognized to have a protean range of clinical manifestations in adults, from respiratory illness to hyperinflammatory and coagulative complications, as well as a broad-spectrum of disease severity. When the epidemic began in China in late December 2019, case reports of pediatric illnesses were absolutely rare, and almost all children had mild clinical courses. However, a growing number of reports from the United Kingdom, Italy, the United States and elsewhere has now described a severe inflammatory syndrome in children similar to Kawasaki’s disease, a vasculitic illness of unclear etiology originally described in Japan in 1967. This syndrome has been named multisystem inflammatory syndrome in children (MIS-C). Case series of MIS-C have described multisystem organ involvement including the mucocutaneous, cardiac, gastrointestinal (GI) and respiratory systems. The mortality rate of MIS-C appears to be low, though severe illness is common and a number of fatalities in children have been reported. Anecdotal reports of MIS-C-like illness have been reported in young adults in their early twenties, raising concern that this rare presentation of COVID-19 may also have some penetrance into younger adult age groups. Herein, we describe a unique case report of MIS-C-like illness in a young adult with COVID-19.

Case Presentation

A 33-year-old previously healthy woman presented to us in emergency department at GBH General Hospital, Udaipur on 28th May, 2021 with the chief complaints of abdominal pain, loose motions, difficulty in breathing since 3 days and fever since 1 day. She was diagnosed with COVID-19 infection on 17th May, 2021. After taking treatment at home, patient was asymptomatic on 25th May, 2021. She was a nonsmoker, nonalcoholic and didn’t use recreational drugs. She was not on any chronic medications and had no known allergies.

On presentation, she was running a fever of 100.4°F, pulse rate varied from 56 to 64 beats per minute, blood pressure of 100/60 mmHg, oxygen level of 91% without oxygen therapy. She appeared ill. On auscultation, patient had bilateral fine crepitations involving lower lobes of the lungs suggestive of heart failure. Cardiac auscultation appeared to be normal. Laboratory work up was notable for profound leukocytosis and acute kidney injury. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) from nasopharyngeal swab was found to be positive. Chest X-ray and computed tomography (CT) scan were done for the patient. CT scan report of the patient, as shown in Figure 1 a and b, was suggestive of area of ground-glass haziness in bilateral lungs in perihilar location, smooth interlobular septal thickening with associated smooth thickening of bilateral oblique fissure, subpleural smooth reticular opacities seen in basal segments of bilateral lungs, and mild bilateral pleural effusion suggestive of pulmonary edema. 2D Echocardiography of the patient was also done which was suggestive of no chamber dilatation with normal left ventricular ejection fraction. Patient was admitted in hospital for hypotension with diagnosis of COVID-19 and concern for possible MIS-C-like illness due to renal, cardiac and GI involvement.

The patient’s blood pressure initially normalized and her creatinine improved to 1.1 mg/dL with the help of vasopressors. During the hospital course, she developed recurrent episodes of bradycardia. Cardiac opinion was taken and creatine phosphokinase-MB (CPK-MB), troponin I, and B-type natriuretic peptide (BNP) levels were sent for analysis. Work-up for these new symptoms revealed evidence of worsening cardiac dysfunction. Level of troponin I was detectable at 0.15 ng/mL and BNP increased to 293 pg/mL (Table 1). She was immediately shifted to contemporary cardiac intensive care unit (CICU) for further management. As the CT scan findings were suggestive of pulmonary edema, with bradyarrhythmia on electrocardiogram, with increase in cardiac markers, the possibility of myocarditis was suspected. Patient was given IV methylprednisolone, IV antibiotics, diuretics and injectable anticoagulants in the form of enoxaparin. Patient was given oxygen support to help in recovering from pulmonary edema early.

With this treatment, patient recovered successfully with mild weakness remaining. Repeat CT scan was done which suggested reduced pulmonary edema. Patient was successfully discharged on oral antibiotics, oral anticoagulation in the form of aspirin, dabigatran, short course of diuretics and mefenamic acid for fever. Patient was followed-up with stable vitals.

Discussion

The Centers for Disease Control and Prevention (CDC)’s case definition for MIS-C is - 1) An individual less than 21 years of age presenting with fever; 2) laboratory evidence of inflammation by one or more markers (such as C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], fibrinogen, etc.); 3) evidence of clinically severe illness requiring hospitalization, with greater than 2 organ systems involved (cardiac, renal, respiratory, hematologic, GI, mucocutaneous or neurological); 4) no other plausible alternative diagnosis; and 5) SARS-CoV-2 infection confirmed by reverse transcription polymerase chain reaction (RT-PCR), serology or antigen testing (or exposure to a suspected or confirmed COVID-19 case within 4 weeks before the symptom onset).

Our patient, a previously healthy young adult woman in her mid-30’s, met these criteria with exception of age.

Several features of our patient’s presentation raised concern for MIS-C-like illness. First, she was noted to have GI tract symptoms in the form of acute abdominal pain and loose motions upon evaluation in emergency department. Additionally, our patient had hypovolemia, bradycardia, acute kidney injury, which responded to vasopressors. While GI symptoms do occur in adults with COVID-19, they are typically less severe; by contrast, prominent GI symptoms are seen in many patients with MIS-C. Finally, our patient’s stable respiratory status was itself a feature shared by patients with MIS-C, who often lack intrinsic respiratory disease.

Other features were potentially compatible with MIS-C-like illness, including low blood pressure, cardiac dysfunction, bradyarrhythmia. Like many patients with MIS-C, our patient required treatment with vasopressors in the ICU. Her low blood pressure was thought to be multifactorial including hypovolemic and cardiogenic. She had elevated troponin and BNP unlike many patients with MIS-C. She didn’t have left ventricular dysfunction, coronary aneurysms or valvular dysfunction, as have been described in pediatric patients with MIS-C.

Several other features of our patient’s clinical presentation were less consistent with MIS-C as it has been described in the pediatric population. Her profound kidney injury and leukocytosis were not features described in majority of MIS-C cases.

Conclusion

We describe an unusual case of MIS-C-like illness in a young adult with COVID-19. MIS-C is an emerging and poorly understood clinical entity associated with COVID-19 that has been described in children with the illness and has features similar to Kawasaki’s disease. Children with MIS-C are increasingly treated with IVIG, aspirin and steroids; it is not clear if any clinical feature in adults may warrant similar treatment approaches. Our patient was treated with IV antibiotics, anticoagulation and steroids. Further research into COVID-19 in the young adult population is needed to better characterize the full range of clinical manifestations, and to identify potential opportunities for targeted treatment of inflammatory processes.

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