Carolinas Research Day 2021

Clinical Case-Based Studies

04 Multisystem Inflammatory Syndrome in Infant With Negative SARS-CoV-2 RT-PCR And Antibodies

Karly A. Derwitz, OMS-IV (1), Hanna S. Sahhar, MD, FAAP, FACOP (1,2)

Edward Via College of Osteopathic Medicine-Carolinas, Pediatric Intensive Care Unit (PICU) at Spartanburg Regional Medical Center

Abstract: Since the declaration of the SARS- CoV-2 pandemic in March 2020 by the World Health Organization, there has been an emergence of a new syndrome termed multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. MIS-C is defined by the presence of fever, systemic inflammation, and multi-organ dysfunction in the context of SARS-CoV-2 infection or COVID-19 exposure. The overall goal of this report is to describe the clinical presentation and successful treatment of an infant diagnosed with MIS-C. A 3-month-old African American male presented to his pediatrician with fevers, abdominal pain, dry cough, diarrhea, and lethargy. Physical exam revealed an erythematous rash on the face and chest with papules on the torso and axilla. The following day he presented to the emergency department with bilateral conjunctivitis and purulent eye discharge. The patient returned on day 5 of his illness with decreased oral intake and urine output and about 10% loss of body weight over two days. SARS-CoV-2 testing was negative, but there may have been unknown exposure within four weeks of onset of symptoms.

Laboratory values supporting signs of inflammation included lymphocytopenia, hypoalbuminemia, elevated C-reactive protein, elevated erythrocyte sedimentation rate and elevated D-dimer. Multisystem organ involvement included the gastrointestinal system with diarrhea, the dermatological system with a rash, and the neurological system due to aseptic meningitis. As the patient met all of the criteria for diagnosis of MIS-C, the decision was made to start an IVIG infusion. The patient showed significant clinical improvement and laboratory values began to normalize. High dose aspirin was given until he remained afebrile for 48 hours. The patient was discharged home on aspirin 5 mg/kg/day for 2 weeks. Four days after discharge, the patient returned to his pediatrician with a fever. Labs showed an elevated white blood cell count. Repeat echocardiogram showed initial signs of coronary artery dilatation. He received a second dose of IVIG in addition to corticosteroids and high-dose aspirin. The patient responded well to treatment, his fever subsided, and laboratory values returned to normal. The patient was discharged home in stable condition.

The clinical presentation of MIS-C is variable, with the majority of cases reporting significant gastrointestinal symptoms, cardiac disease, mild or absent respiratory symptoms, rash, conjunctivitis, and oral mucous membrane changes. Limitations of our study include absence of COVID-19 diagnosis. The timing and sensitivity of available SARS-CoV-2 tests may affect the accuracy of the results and unknown exposure to COVID-19 should not exclude MIS-C from the differential diagnosis. Given that the understanding of MIS-C is still evolving, it is important to closely follow potential MIS-C patients as the physical exam findings do not appear simultaneously but rather evolve over several days. If MIS-C goes undiagnosed the deterioration can be quite rapid and severe resulting in high mortality rates. Increased index of suspicion and early decision to initiate intensive care are critical in successfully treating MIS-C.

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