MULTISYSTEM INFLAMMATORY SYNDROME OF THE ADULT: AN IMPORTANT CONSEQUENCE OF COVID-19

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Multi-system inflammatory syndrome of the adult (MIS-A) has been recently brought to light by the COVID-19 pandemic. MIS-A is characterized by high fever, elevated inflammatory markers and multi-organ dysfunction. The most commonly affected organs are the cardiac and gastrointestinal systems. Guideline directed treatment has yet to be established. CASE PRESENTATION: A 24 year old male with a history of SARS-COV-2 infection presented to the hospital with a chief complaint of nausea and vomiting. Over the previous few days, the patient reported diarrhea along with high fevers and dyspnea. He was diagnosed with COVID-19 six weeks prior, and his disease course was self-limited. He completed his quarantine with no lasting effects.Vital signs revealed a temperature of 103.6 degrees Fahrenheit, heart rate of 141 beats per minute and a respiratory rate of 29 breaths per minute. He was saturating 89% on room air. He was treated for sepsis with isotonic crystalloids and empiric antibiotics. His oxygen requirement eventually improved with diuresis. The remainder of his laboratory workup was significant for an elevated troponin which peaked at 0.93 ng/mL and an elevated c-Reactive protein of 36.07 mg/dL. His echocardiogram revealed an ejection fraction of 30-35%, left ventricular hypokinesis and an RVSP of 40 mmHg. He was started on intravenous methylprednisolone 60mg q6h with rapid improvement of symptoms, and full dose anticoagulation for an NSTEMI. DISCUSSION: In October of 2020, a report was published by the CDC reviewing 9 cases of MIS-A that were submitted directly, and 7 of which were published from case reports. Five criteria for the diagnosis of MIS-A included severe illness requiring hospitalization in a patient > 21 years of age, currently positive or previous SARS-CoV-2 infection in the last 12 weeks, dysfunction of one or more extra-pulmonary organ systems, elevated inflammatory markers (CRP, ferritin, d-dimer or IL-6) and absence of severe respiratory illness. Of the 16 cases that were reported, 75% were febrile. All patients had evidence of cardiac injury, and 13 out of 16 had gastrointestinal symptoms. All patients also had elevated laboratory markers of inflammation. Treatment varied, as patients were given IVIG, corticosteroids and anti-IL-6 therapies. CONCLUSIONS: Our patient met all criteria for MIS-A. Although he had respiratory symptoms, they improved rapidly with diuresis, which suggests that they may have been related to myocarditis and reduced ejection fraction, rather than a primary pulmonary process such as pneumonia. This case highlights the importance of recognizing MIS-A as a sequela of COVID-19 infection. It can occur weeks after initial COVID-19 infection, or concomitantly with infection and PCR positivity. Treatment has not been clearly established, but our patient improved rapidly with corticosteroid administration and supportive care. REFERENCE #1: Morris, S., Schwartz, N. et. al. (2020). Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection - United Kingdom and UnitedStates - March - August 2020. Morbidity and Mortality Weekly Report, 69(40). REFERENCE #2: Tenforde, M., & Morris, S. (2021). Multisystem Inflammatory Syndrome in Adults. CHEST, 159(2). doi:https://doi.org/10.1016/j.chest.2020.09.097 DISCLOSURES: No relevant relationships by SUNIL KUMAR, source=Web Response No relevant relationships by Julia Ladna, source=Web Response No relevant relationships by Kenneth Wojnowski, source=Web Response