Ananya Ghosal, MAKAUT(WB)
In the SARS-CoV-2 pandemic, new information is showing us the path of the disease. Multisystem Inflammatory Syndrome (MIS) is an example of a complication that is also described as a hyper-inflammatory syndrome, where the characteristics are the same as Kawasaki disease. From the publication of CDC, 27 adult cases were reported which were similar to the description of MIS. Some of the characteristics patients presented show concern for MIS-A or Kawasaki-like illness. Symptoms of Kawasaki disease are 5 days of fever and clinical features are extremity changes, oral changes, conjunctivitis, cervical lymphadenopathy, and rash. The two differences between Kawasaki and MIS-C are ethnic distribution and age distribution.
The patient suffering from MIS-A was found to have 4 out of 5 clinical symptoms but didn’t have rashes. The patient improved after 3 days dose of methylprednisolone 125mg/d, an oral prednisone taper 50mg/d. The patient received IV immunoglobulin for 2 days and ASA 325. This treatment continued until clinical resolution which led to normal C-reactive protein and absence of fever. Echocardiography is used to detect the diameter of the coronary artery but when the body size increases CT Coronary angiography is preferred.
What happens in MIS?
The patient with no known comorbidity and not vaccinated against SARS-CoV-2, tested positive for SARS-CoV-2 confirmed by PCR testing. He reported lymph node enlargement on the left side of his neck and it resolved 2 days before he got admitted in an emergency with profound fatigue, fever up to 40°C, anorexia, and mild shortness of breath. Respiratory examination of the patient showed air entry was good bilaterally, without crackles and crepitus. He had erythema of the distal portion of his toes bilaterally, bilateral pitting edema, erythema, enlargement of his tongue, and bilateral non-purulent conjunctivitis. The result of chest radiography showed right lower lobe opacification. An electrocardiograph clearly showed atrial fibrillation accompanied with a rapid ventricular response. Computed tomography was negative for pulmonary embolism. However, showed early pulmonary edema and heart enlargement.
The patient was suspected of possible bacterial pneumonia as a superinfection for its previous history of SARS-CoV-2 and started the treatment with empirical piperacillin-tazobactam. Acute inflammation indicated by D-Dimer leukocytosis with neutrophilia, ferritin, and elevated C-reactive protein. There was an increase in troponin level and the patient substantially increase in pro-brain-type natriuretic peptide level. Urine culture, blood culture, and a respiratory viral panel turned out to be negative. The patient was immune to Hepatitis B and tested negative for Hepatitis C, HIV, and autoimmune workup which was collected before the initiation of therapy. However, Covid-19 immunoglobulin G serology was positive. Corticosteroids were done before the transthoracic echocardiogram and the result showed normal sinus rhythm and normal left and right ventricular systolic and diastolic function. The patient was suspected of inflammatory post-Covid-19 syndrome. With the symptoms of oral mucosal changes, conjunctivitis, cervical lymphadenopathy, and lower extremity changes, these are the criteria for multi-system inflammatory syndrome in adults (MIS-A). He also had multiple features same as MIS-C.
Recovery
The patient reported substantial improvement in energy level, anorexia, reduction in inflammatory markers, improved conjunctivitis, documented resolution of fever, and decreased erythema of his tongue within 24hrs after the treatment of Acetylsalicylic acid (ASA) and methylprednisolone and discontinuation of antibiotics. After the echocardiogram report was normal the patient was discharged home just five days after admission. The patient improved clinically and biochemically.
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Reference:
- Kerkerian, G., & Vaughan, S. D. (2021). Multisystem inflammatory syndrome in an adult after SARS-CoV-2 infection. Canadian Medical Association Journal, 193(25), E956–E961. https://doi.org/10.1503/cmaj.210232
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