DO NOT MISS MIS-A: MULTISYSTEM INFLAMMATORY SYNDROME IN AN ADULT AFTER COVID-19

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Reports indicate a rare but serious complication of coronavirus disease 2019 (COVID-19) in children is a multisystem inflammatory syndrome in children (MIS-C). The cause of this is yet to be found. However, since the summer of 2020, some case reports have documented multisystem inflammatory syndrome in adults (MIS-A). CASE PRESENTATION: A 37-year-old male with a past medical history of diabetes and tobacco use presented to the emergency department (ED) for two days of fever, chest pain, and dyspnea. He had been diagnosed with COVID-19 and quarantined at home without symptom progression 17 days prior to his ED visit. In the ED, the patient was found to have a temperature of 39°C, heart rate of 145 bpm, and blood pressure of 95/41 mmHg. Lab values showed a creatinine of 4.74 mg/dL, lactic acid 4.7 mmol/L, C-reactive protein 640.4 mg/L, sedimentation rate 108 mm/hr, ferritin 2126 mcg/L, D-Dimer 2770 ng/mL and pro-B-type natriuretic peptide 629 ng/L. Chest computed tomography angiogram was negative for pulmonary embolism;however, it did show mediastinal lymphadenopathies (Figure 1). The patient was given intravenous fluids, piperacillin-tazobactam, vancomycin, and started on norepinephrine followed by admission to the medical intensive care unit (MICU). In the MICU, the patient required a second vasopressor (vasopressin) and hydrocortisone. Nephrology was consulted to start continuous renal replacement therapy. An echocardiogram revealed new-onset heart failure with an ejection fraction of 40%. Infectious, hematologic, and autoimmune investigations continued to be unremarkable;however, the patient's COVID-19 antibodies were reactive to spike and nucleocapsid antigens. After three days of treatment, the patient no longer required vasopressor support, and steroids were discontinued. Even so, the next morning he was again febrile and hypotension requiring vasopressors as well as new-onset atrial fibrillation with controlled rate. On exam, he developed a new non-blanching rash of his bilateral feet (Figure 2). Thereafter, infectious disease was consulted and diagnosed the patient with MIS-A. They started steroids along with intravenous immunoglobulin. This regimen saw a rapid resolution in fevers, despite holding antibiotics. DISCUSSION: Common symptoms of MIS-A are fever, chest pain, palpitations, and gastrointestinal distress. Elevated inflammatory markers include C-reactive protein, ferritin, and D-dimer [1]. Both children and adults have been reported to have cardiac dysfunction with MIS [1,2]. Recently the most common therapies provided to patients with MIS-C and -A are IVIG, vasoactive medications, and steroids [3]. CONCLUSIONS: Though MIS-C has been recognized in the pediatric population, MIS-A is beginning to present in adults after a COVID-19 infection. Increased awareness, as well as further study of this syndrome's pathophysiology, may lead to rapid treatment and improved outcomes. REFERENCE #1: Morris SB, Schwartz NG, Patel P, et al. Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection — United Kingdom and United States, March–August 2020. MMWR Morb Mortal Wkly Rep 2020;69:1450–1456. DOI: http://dx.doi.org/10.15585/mmwr.mm6940e1 REFERENCE #2: Belhadjer, Z., Meot, M., Bajolle, F., Khraiche, D., Legendre, A., Abakka, S., Auriau, J., Grimaud, M., Oualha, M., Beghetti, M., Wacker, J., Ovaert, C., Hascoet, S., Selegny, M., Malekzadeh-Milani, S., Maltret, A., Bosser, G., Giroux, N., Bonnemains, L., Bordet, J., … Bonnet, D. (2020). Acute Heart Failure in Multisystem Inflammatory Syndrome in Children in the Context of Global SARS-CoV-2 Pandemic. Circulation, 142(5), 429–436. REFERENCE #3: Abrams, J. Y., Godfred-Cato, S. E., Oster, M. E., Chow, E. J., Koumans, E. H., Bryant, B., Leung, J. W., & Belay, E. D. (2020). Multisystem Inflammatory Syndrome in Children Associated with Severe Acute Respiratory Syndrome Coronavirus 2: A Systematic Review. The Journal of pediatrics, 226, 45–54 e1. Advance online publication. https://doi.org/10.1016/j.jpeds.2020.08.003 DISCLOSURES: No relevant relationships by Ojobumijo Agbaji, source=Web Response No relevant relationships by Abdelrahman Elfaham, source=Web Response No relevant relationships by Michael Hubbard, source=Web Response No relevant relationships by Tyler Kemnic, source=Web Response No relevant relationships by Micah Larsen, source=Web Response No relevant relationships by Amy Rechenberg, source=Web Response Site PI for VENT AVOID trial relationship with A-Lung Please note: $1-$1000 Added 12/03/2020 by Maximiliano Tamae Kakazu, source=Web Response, value=No direct payment to me