SEVERE MULTISYSTEM INFLAMMATORY SYNDROME IN AN ADULT WITH MYOCARDITIS

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: There have been increasing reports of a rare hyperinflammatory syndrome seen in children following Coronavirus disease 2019 (COVID-19) with shared features of Kawasaki's Disease (KD). More recently, cases involving adolescents and young adults are emerging [1]. We present a case of severe multi-system inflammatory syndrome with myocarditis in a young adult. CASE PRESENTATION: A 20-year-old male with beta-thalassemia trait and a family history of Sjogren disease presented for screening after contact with a friend who tested positive for COVID-19. PCR testing confirmed COVID-19. He was asymptomatic at that time and was advised to quarantine at home.Five weeks later, he presented with a high-grade fever of 104 F, myalgias, difficulty breathing, chest pain, palpitations, hematuria, and hematochezia. Vital signs showed tachycardia (127 bpm) and hypotension (90/53 mmHg). Chest X-ray showed no infiltrates. Electrocardiogram (EKG) showed no ST abnormalities. Nasopharyngeal PCR was negative for COVID-19. Labs showed elevated C-reactive protein (CRP), creatinine phosphokinase (CPK), and lactate (8.0 mmol/L). Troponin T was elevated to 1.5 ng/L, and high sensitivity troponin was 12759 ng/L. Sequential Organ Failure Assessment (SOFA) score was 9. He was admitted to the intensive care unit (ICU) for cardiogenic vs distributive shock. Echocardiogram revealed new-onset reduced ejection fraction (EF) at 20%, with no wall motion abnormalities. He was anuric with rhabdomyolysis and acute tubular necrosis. He was treated with hemodialysis, intravenous N-acetylcysteine protocol, inotropic support, three doses of intravenous immunoglobulins (IVIG), corticosteroids, and aspirin. Serial blood cultures were negative. He had a high serum titer of COVID-19 antibody. Patient slowly improved following IVIG treatment and supportive care, with decreasing SOFA score. He was weaned off pressors and dialysis. Repeat echocardiogram showed recovered EF at 45%, and inflammatory markers improved to normal. After a 3-week hospital course, patient was near baseline with post-ICU deconditioning. DISCUSSION: Multisystem Inflammatory Syndrome in Adults (MIS-A) is a rare post-infectious sequela of COVID-19 with shared features of KD. Proposed mechanisms include direct hypoxic, ischemic injury, and post-viral immune-mediated vasculitis. Patients usually have limited respiratory involvement, evidence of recent COVID-19, and high antibody titers, which supports a post-infectious, immune-mediated etiology. Myocarditis is more common compared with Kawasaki disease, and both can have coronary artery aneurysms. Limited data from case series show good outcomes with IVIG, corticosteroids, and aspirin [2]. CONCLUSIONS: MIS is a rare extrapulmonary complication of COVID-19 with a wide spectrum of presentation. Initially described in children, more cases are emerging in young adults. A multidisciplinary approach is essential in severe cases. REFERENCE #1: Hékimian G, Kerneis M, Zeitouni M, et al. Coronavirus Disease 2019 Acute Myocarditis and Multisystem Inflammatory Syndrome in Adult Intensive and Cardiac Care Units. Chest. 2021;159(2):657-662. doi:10.1016 REFERENCE #2: Godfred-Cato S, Bryant B, Leung J, Oster ME, Conklin L, et al. California MIS-C Response Team. COVID-19-Associated Multisystem Inflammatory Syndrome in Childre, March-July 2020. MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1074-1080. doi: 10.15585 DISCLOSURES: No relevant relationships by Mateus Fernandes, source=Web Response No relevant relationships by Ifediba Nwachukwu, source=Web Response