Abstract
Historically, children evaluated for vomiting and diarrhea secondary to viral enteritis have symptoms lasting 2–4 days and respond to supportive care, including oral rehydration and anti-emetics if required. Recently, within a 14-day timespan, we encountered three children with severe diarrhea who rapidly became dehydrated and went into hypotensive shock. Although SARS-CoV-2 molecular tests were negative by nasopharyngeal swab, all were later found to have MIS-C. This small case series underscores features reported in previous larger studies and emphasizes the rapid clinical evolution of this condition. We highlight the importance of early recognition of cardinal laboratory findings characteristic of MIS-C (i.e., lymphopenia, markedly elevated acute phase reactants, and hypoalbuminemia). We also show serologic evidence that the pathophysiological mechanism of SARS-CoV-2 related diarrhea may differ from other causes of dehydrating vomiting and diarrhea, with no serologic evidence of villus cell injury.
Highlights
In recent decades, acute viral gastroenteritis has rarely progressed to hypotension in the United States (U.S.), in developing countries, enterotoxin-secreting microbes and one particular virus, rotavirus, can induce a secretory diarrhea resulting in severe dehydration [1, 2]
We present a case series of three children who met the CDC criteria for multisystem inflammatory syndrome in children (MIS-C) based on the presence of fever, multiorgan involvement, elevated laboratory markers (Table 1), lack of alternate etiology and presence of positive SARS-CoV-2 immunoglobulin G (IgG)
Based on our findings of normal claudin 3 and I-FABP, and elevated zonulin in this small case series of diarrhea predominant MIS-C, we believe that the diarrhea is due to a leaky gut triggered by increased zonulin
Summary
Acute viral gastroenteritis has rarely progressed to hypotension in the United States (U.S.), in developing countries, enterotoxin-secreting microbes and one particular virus, rotavirus, can induce a secretory diarrhea resulting in severe dehydration (generally with >10–20 stools/day) [1, 2]. We present a case series of three children who met the CDC criteria for MIS-C based on the presence of fever, multiorgan involvement, elevated laboratory markers (Table 1), lack of alternate etiology and presence of positive SARS-CoV-2 immunoglobulin G (IgG). The similarity in this cohort of children was the severe acute watery diarrhea leading to shock with rapid response to anti-inflammatory therapy, similar to another recent case series of children requiring inotropic support with acute watery diarrhea [6].
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